Health inspection·October 13, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some activities was not comprehensive and person-centered, and the interventions did not specify the activities to be provided and did not have the frequency of the visits provided. MDSC further verified that there was no measurable outcome for the visits in the care plan. During a concurrent interview with activities director (AD) and record review of Resident 14's care plans on 10/13/23 at 10:40 a.m., AD verified that Resident 14's care plan for her activities was not comprehensive and person-centered, and the interventions did not specify the activities to be provided and did not have the frequency of the visits provided. AD further verified that there was no measurable outcome for the visits in the care plan. During an interview with the director of nursing (DON) on 10/13/23 at 2:55 p.m., DON verified that the activity care plan of Resident 14 should have been comprehensive and person-centered. DON further verified the care plan should have specified the services provided and the frequency of the visits. Review of Resident 41's clinical record indicated, Resident 41 was an [AGE] year-old female, admitted to the facility last 4/25/23, with diagnoses including, hemiplegia (complete paralysis of one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (also known as stroke, refers to damage to tissues in the brain due a loss of oxygen to the area) affecting left non-dominant side, dysphagia (difficulty swallowing) and type 2 diabetes mellitus (adult onset, high blood sugar). During an observation of Resident 41 on 10/9/23 at 2:17 p.m., Resident 41 was sitting in her wheelchair, alert, calm, and comfortable. Review of Resident 41's active physician orders as of 10/11/23, indicated, Resident 41 may participate in activities if not in conflict with treatment plan, initiated, 4/25/23. Review of Resident 41's care plan for her activities indicated, the staff to provide one on one bedside or in-room visits and activities. The activity care plan did not describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being and there was no frequency and timetable in the intervention provided and no measurable outcome of the visits. During a concurrent interview with MDSC and record review of Resident 41's care plans on 10/13/23 at 10:19 a.m., MDSC verified that Resident 41's care plan for her activities was not comprehensive and person-centered, and the interventions did not specify the activities to be provided and did not have the frequency of the visits provided. MDSC further verified that there was no measurable outcome for the visits in the care plan. During a concurrent interview with AD and record review of Resident 41's care plans on 10/13/23 at 10:40 a.m., AD verified that Resident 41's care plan for her activities was not comprehensive and person-centered, and the interventions did not specify the activities to be provided and did not have the frequency of the visits provided. AD further verified that there was no measurable outcome for the visits in the care plan. During an interview with the DON on 10/13/23 at 2:55 p.m., DON verified that the activity care plan of Resident 41 should have been comprehensive and person-centered. DON further verified that the care plan should have specified the services provided and the frequency of the visits. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 2 of 21 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 10/13/2023 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Review of Resident 160's clinical record indicated, Resident 160 was a [AGE] year old male, admitted to the facility last 9/28/23, with diagnoses including, displaced intertrochanteric fracture (extracapsular fracture of the proximal femur that occur between the greater and lesser trochanter) of right femur (thigh bone), hypertension (high blood pressure) and history of falling. During an observation of Resident 160 on 10/9/23 at 1:55 p.m., Resident 160 was laying in his bed, alert, oriented, calm and verbally responsive. Review of Resident 160's active orders as of 10/11/23, indicated, Resident 160 may participate in activities if not in conflict with treatment plan, initiated, 9/28/23. Review of Resident 160's care plan for his activities indicated, there were no interventions or tasks formulated for his activity care plan. There were no specific services that were to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, no frequency of the services and no measurable outcomes of the services. During a concurrent interview with MDSC and record review of Resident 160's care plans on 10/13/23 at 10:19 a.m., MDSC verified that Resident 160's care plan for her activities was not comprehensive and person-centered. MDSC further verified that there were no interventions or tasks formulated for his activity care plan and there were no specific services that were to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, no frequency of the services and no measurable outcomes of the services. During a concurrent interview with AD and record review of Resident 160's care plans on 10/13/23 at 10:40 a.m., AD verified that Resident 160's care plan for her activities was not comprehensive and person-centered, and there were no interventions or tasks formulated. During an interview with the DON on 10/13/23 at 2:55 p.m., DON verified that the activity care plan of Resident 160 should have been comprehensive and person-centered. DON further verified that the interventions or tasks in the activity care plan should have been formulated already with specific services to be provided, frequency of the services provided and the measurable outcomes of the services. 3. A review of Resident 18's clinical record indicated Resident 18 was admitted to the facility on [DATE] with diagnoses including sequelae of cerebral infarction (area of brain tissue that dies because of localized hypoxia/ischemia due to a cessation of blood flow), dysphagia swallowing difficulties), unspecified dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities) without behavioral disturbance. During an observation of Resident 18 on 10/9/2023 at 8:44 a.m., Resident 18 was sleeping in bed. During an observation of Resident 18 on 10/11/2023 at 10:01 a.m., Resident 18 was sleeping in bed. A record review of Resident 18's physician order dated 9/6/2023, indicated, administering Modafinil, 100 mg, 1 tablet via percutaneous endoscopic gastrostomy (PEG, a feeding tube that is placed into a patient's stomach) tube, daily for excessive sleepiness. A review of Resident 18's care plan indicated, the excessive sleepiness problem was not addressed in the care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 3 of 21 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 10/13/2023 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review with the Director of Staff development (DSD) on 10/12/2023 at 2:42 p.m., DSD confirmed after reviewing Resident 18's care plan that Resident 18's excessive sleepiness was not addressed in her care plan. DSD further stated, Resident 18 had been taking Modafinil to treat excessive daytime sleepiness since 9/6/2023 and nurses should have developed a comprehensive person-centered care plan to track the progress toward the therapeutic goals. Residents Affected - Some During an interview with the Director of Nursing (DON) on 10/13/2023 at 2:00 p.m., the DON stated the licensed nurses should have been address Resident 18's excessive sleepiness issue in the care plan. Review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised December 2016, 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 comprehensive, person-centered care plan will include measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being and reflect treatment goals, timetables and objectives in measurable outcomes. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident. The comprehensive, person-centered care plan is developed within 7 days of the completion of the required comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 4 of 21 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 10/13/2023 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)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for three of 15 sampled residents (Residents 16, 18, and 21) when: Residents Affected - Some 1. Resident 16, there were two duplicated insulin orders without parameters; 2. Resident 18, the treatment nurse did not label the dressing with the date, time, and initial and; 3. Resident 21, the licensed nurse did not refill her eye drop medicine on time and caused six missed treatments. These failures had the potential to negatively affect the residents' health and well-being. Findings: 1. A review of Resident 16's clinical record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (type 2 DM, adult onset high blood sugar) with diabetic neuropathy (the presence of symptoms or signs of peripheral nerve dysfunction in people with diabetes), type 2 diabetes mellitus with unspecified diabetic retinopathy (an eye condition that can cause vision loss and blindness in people who have diabetes) without macular edema. A review of Resident 16's physician order dated 3/26/2023 indicated, Novolog (medication for blood sugar) FlexPen Solution Pen-injector 100 unit/ml (insulin Aspart), inject 15 units subcutaneously with meals for Type 2 DM, if blood sugar (BS) < 150; give 20 units if BS> 150; NovoLog FlexPen Solution Pen-injector 100 unit/ml (insulin Aspart) inject 20 units subcutaneously with meals for Type 2 DM if BS is >150; give 15units if BS is <150. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) A on 10/11/2023 at 11:45 a.m., LVN A stated that the above orders were duplicated without parameters for low blood sugar and had caused confusion. During a concurrent interview and record review with the Director of Staff Development (DSD) on 10/13/2023 at 10:03 a.m., the DSD reviewed Resident 16's physician order and confirmed, the above orders were duplicated and incomplete. The DSD further stated that the nurse who received the orders needed to clarify with the doctor for parameters to prevent medication errors. 2. During a concurrent observation and interview with the treatment nurse (TN) on 10/12/2023 at 10:20 a.m., there was a dressing without a label of the date, time and initial under Resident 18's PEG tube. The TN removed the dressing and cleaned the area of the PEG tube, then placed a new one under the tube without labeling the dressing with date, time, and initial. During an interview with TN on 10/12/2023 at 10:30 a.m., the TN acknowledged that she did not label the dressing with the date, time, and initial. During an interview with the DSD on 10/13/2023 at 10:03 a.m., the DSD stated that the TN should have been labeled the dressing with date, time, and initial for next-shift nurses to track. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 5 of 21 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 10/13/2023 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm During an interview with the DON on 10/13/2023 at 2:00 p.m., the DON stated the nurses should have label the dressing with date, time, and initial according to the facility policy and procedure. A review of the facility's policy and procedure titled, Dressing, Dry/Clean, Revised September 2013, indicated, .label tape or dressing with date, time and initials . Residents Affected - Some 3. A review of Resident 21's clinical record indicated, Resident 21 was admitted to the facility on [DATE] with diagnoses including unspecified glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eyes). A review of Resident 21's physician order indicated, instilling one drop of Dorzolamide (medication for the eyes) Hydrochloride and Timolol Mal (medication for the eyes), in both eyes twice daily for glaucoma. During a concurrent observation and interview with the nurse supervisor on 10/9/2023 at 5:16 p.m., she stated the registered nurse (RN E) did not instill the Dorzolamide eye drops in Resident 21's eyes during the medication pass. RN B stated that there were no Dorzolamide eye drops in the medication cart for Resident 21. During an interview and concurrent record review with licensed vocational nurse (LVN B) on 10/9/2023 at 5:30 p.m., LVN B reviewed Resident 1's nursing note dated 10/6/2023 to 10/9/2023 and confirmed, there was no Dorzolamide eye drops available for Resident 21 since 10/6/2023, and the licensed nurse reordered on the same day. LVN B stated that nurses should have refill the medication when there was a 3-to-4-day supply left. LVN B further stated, those missed treatments would make Resident 21, not receive the medication's full therapeutic effects. During a concurrent interview and record review with the DON on 10/13/2023 at 2:00 p.m., the DON confirmed, six missed Dorzolamide eye drops treatment for Resident 21's glaucoma, from 10/6-10/9. The DON stated that the nurses should have check the expired medications frequently and refill medications, 3 to 5 days before the last dosage. A review of the facility's policy and procedure titled Medication and Treatment orders, Revised July 2016, indicated, .Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three days prior to the last dosage being administered to ensure that refills are readily available . A review of the facility's undated Medication Delivery Cut Off time Schedule, indicated .refills should have been ordered when there is a 3-to-5-day supply left in the card . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 6 of 21 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 10/13/2023 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)

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** Based on observation, interview and record review, the facility failed to ensure the residents received the necessary care and services for five of 15 residents (2, 8, 20, 22, and 37) when: Residents Affected - Some 1. Licensed nurses did not follow the physician's order for pain medication based on the resident's pain level for Resident 2; 2. A bottle of gel hand sanitizer was on Resident 8's night stand in her room; 3. Licensed nurse did not follow the physician's order for oxygen supplement for Resident 20; 4. Licensed vocational nurse G (LVN G) did not know how to monitor Resident 22's AV fistula (a special connection that is made by joining a vein onto an artery, usually in the arm) and what to do if it was bleeding; and 5. LVN G did not know how to monitor the signs and symptoms if the pacemaker would malfunction for Resident 37. These failures had the potential to affect the residents' care and could jeopardize their health and well-being. Findings: 1. Review of Resident 2's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 2' physician order, dated 3/26/22, indicated she had an order for Tylenol (medication used to treat minor pains) 325 milligrams (mg, a metric unit of mass) give two tablets every 6 hours as needed for pain level 1 to 3; and Norco (medication used to relieve moderate to severe pain) 5-325 mg every 4 hours as needed for pain level 4 to 10. However, review of Resident 2's Medication Administration Record (MAR), dated 8/2023 and 9/2023, indicated the licensed nurses administered Norco 5-325 mg to Resident 2 when she had pain level below 4 on 8/8/23, 8/23/23, 8/28/23, 9/19/23, 9/25/23, and 9/28/23. During an interview with the director of nursing (DON) on 10/13/23 at 2:38 p.m., she reviewed Resident 2's 8/2023 and 9/2023 MARs and confirmed the licensed nurses administered Norco 5-325 mg to Resident 2 when she had pain level below 4 on 8/8/23, 8/23/23, 8/28/23, 9/19/23, 9/25/23, and 9/28/23. The DON stated the licensed nurses should have administered Tylenol to Resident 2 when she had pain level below 4. Review of the facility's policy, Administering Pain Medications, dated 10/2010, indicated . Steps in the Procedure: . 6. Administer pain medications as ordered. 2. Review of Resident 8's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 7 of 21 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 10/13/2023 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 10/9/23 at 1:09 p.m., Resident 8 was lying in bed and was able to turn, grab, and pull the blanket to cover herself. A 354 milliliters (ml, a metric unit of volume) bottle of gel hand sanitizer was on Resident 8's bedside night stand. The hand sanitizer bottle was 2/3 full. During an observation and interview with license vocational nurse B (LVN B) on 10/9/23 at 1:11 p.m., he picked up the hand sanitizer bottle and stated it should have not left inside Resident 8's room. During an interview with the director of staff development (DSD) on 10/13/23 at 2:10 p.m., she stated the certified nursing assistant (CNA) in night shift used the hand sanitizer bottle and left it there on Resident 8's night stand. The DSD stated the CNA should have not left the hand sanitizer bottle there with Resident 8's room because the residents could drink it. Review of the facility's policy, Safety and Supervision of Residents, dated 7/2017, indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 3. Review of Resident 20's admission Record indicated he was admitted to the facility on [DATE] with acute respiratory failure diagnosis. Review of Resident 20's physician order, dated 8/23/23, indicated he had an order for oxygen (therapy that provides extra air to breathe in) at 2 liters (L, a metric unit of volume) per minute via nasal cannula (device used to deliver supplemental or air to a resident) continuously every shift. During an observation and interview with license vocational nurse B (LVN B) on 10/9/23 at 11:44 a.m., Resident 20 was lying in bed and the resident was on 3 L of oxygen per minute. LVN B stated Resident 20 should have administered 2 L of oxygen per minute as ordered. Review of the facility's policy, Medication Administration - General Guidelines, dated 4/2008, indicated . Procedures: . B. Administration: . 2. Medications are administered in accordance with written orders of the attending physician. 4. Review of Resident 22's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis (the machine removes waste and extra fluid from the blood before pumping it back into the body; the blood leaves and then returns to the body through a needle, usually in the arm, neck, or leg). Review of Resident 22's physician orders, dated 6/21/21, indicated he had orders for the licensed nurses to check his AV fistula site on his left forearm for bruit (a whooshing sound heard by using a stethoscope) and thrill (a vibration caused by blood flowing through the fistula and can be felt by placing the fingers just above the incision line) every shift, to observe his AV fistula site for redness, swelling, and bleeding every shift, and if bleeding was apparent, apply direct pressure over the dialysis access site and call the physician immediately. During an interview with licensed vocational nurse G (LVN G) on 10/11/23 at 11:14 a.m., she stated she was the assigned licensed nurse for Resident 22. LVN G stated she checked Resident 22's AV fistula site for redness, swelling, bleeding, and bruit. LVN G stated she did not know anything else to check on Resident 22's fistula site. LVN G stated she checked the bruit by observing the fistula site, and if the site was bleeding, she would wrap it up so that the blood did not go everywhere and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 8 of 21 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 10/13/2023 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)

F 0684 call the physician. Level of Harm - Minimal harm or potential for actual harm During an interview with the DON on 10/13/23 at 3:13 p.m., she stated the licensed nurses should know they should check the thrill and know how to check bruit and thrill, and she should have applied direct pressure on the site if it was bleeding as ordered by the physician. Residents Affected - Some Review of the facility's policy, Hemodialysis Access Care, dated 9/2010, indicated . Steps in the Procedure: . h. Check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access. Care Immediately Following Dialysis Treatment: . If there is bleeding from site, apply pressure to insertion site . 5. Review of Resident 37's admission Record indicated she was admitted to the facility on [DATE] with presence of cardiac pacemaker (a small battery-operated device implanted in the chest that helps the heart beat in a regular rhythm) diagnosis. Review of Resident 37's physician order, dated 3/6/23, indicated she had an order for the licensed nurse to observe her and report signs and symptoms of pacemaker malfunction such as pulse less than 60, and/or shortness of breath, chest pain, dizziness, altered level of consciousness (ALOC), prolonged hiccups, chest muscle twitching, swelling of both legs and ankles, fainting or palpitations (rapid pulsations or abnormally rapid or irregular beating of the heart), hypotension (low blood pressure) every shift. During an interview with LVN G on 10/11/23 at 11:21 a.m., she stated she was the assigned licensed nurse for Resident 37. LVN G stated she checked the malfunction of Resident 37's pacemaker by checking her apical pulse (a pulse point on the chest at the bottom tip of the heart), and she would call the physician if the apical pulse was less than 60. LVN G stated she did not know any other signs or symptoms to monitor for the malfunction of Resident 37's pacemaker. During an interview with the DON on 10/13/23 at 2:32 p.m., she stated the physician had already ordered to monitor Resident 37 for signs and symptoms of the pacemaker malfunction, the licensed nurses should have known about these signs and symptoms of the pacemaker malfunction. Review of the facility's policy, Pacemaker, Care of a Resident with a, dated 12/2015, indicated . Monitoring: Monitor the resident for pacemaker failure by monitoring for signs and symptoms including: syncope, shortness of breath, dizziness, fatigue, and/or confusion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 9 of 21 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 10/13/2023 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)

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 meet the needs of two residents (13 and 20) when they were simultaneously administered two medications with drug-to-drug interaction (situation in which a drug affects the activity of another drug when both are administered together). This interaction may decrease the therapeutic effect of the medications for the residents. Findings: Review of Resident 13's admission Record indicated, she was admitted to the facility on [DATE] with anemia (a low number of red blood cells) diagnosis. Review of Resident 13's clinical record indicated, she had physician orders for ferrous sulfate (a supplement used to prevent or treat low blood iron levels) 220 milligrams (mg, a metric unit of mass) per 5 milliliters (ml, a metric unit of volume) daily at 9 a.m., started on 7/21/23, and for calcium carbonate (a medication used to prevent or treat low blood calcium levels) 500 mg, give two tablets daily at 9 a.m., started on 7/21/23. Thus, since 7/21/23, ferrous sulfate and calcium carbonate were given daily at the same time at 9 a.m. Review of Resident 20's admission Record indicated, he was admitted to the facility on [DATE] with iron deficiency anemia secondary to blood loss diagnosis. Review of Resident 20's clinical record indicated, he had physician orders for ferrous sulfate 220 mg/5 ml, give 7.5 ml daily at 9 a.m., started on 8/24/23, and for Calcium 600-D (a medication used to prevent or treat low blood calcium levels) 600-400 mg-unit, two times daily at 9 a.m. and 5 p.m., started on 8/24/23. Thus, since 8/24/23, ferrous sulfate and Calcium 600-D were given daily at the same time at 9 a.m. During an interview with the pharmacy consultant (PC), on 10/13/23 at 2:55 p.m., she stated the ferrous sulfate and calcium should have administered at least one to two hours apart to avoid drug-to-drug interaction that may decrease the absorption of ferrous sulfate. During an interview with the director of nursing (DON) on 10/13/23 at 3:05 p.m., she confirmed the ferrous sulfate and calcium should have not given at the same time to Resident 13 and Resident 20. According to Lexicomp (www.[NAME].com), a nationally recognized drug information resource, the concurrent use of calcium and ferrous sulfate led to a drug-drug interaction (DDI) of Risk Rating D, which was a significant interaction and required therapy modification. The effect of the DDI was that the calcium may decrease the absorption of oral preparations of iron salts. It indicated the iron absorption was decreased an average of 60% when given as ferrous sulfate and co-administered with calcium. Lexicomp also indicated to separate the administrations of these medications so it may minimize the potential for significant interaction. Review of the facility's policy, Medication Regimen Review, dated 4/2008, indicated, The consultant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 10 of 21 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 10/13/2023 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 11 of 21 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 10/13/2023 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 4. Review of Resident 26's admission Record indicated she was admitted to the facility on [DATE]. During an observation and interview with licensed vocational nurse D (LVN D) on 10/9/23 at 11:08 a.m., two 100-milliliters (ml, a metric unit of volume) bottles of normal saline (NS, a 0.9% sterile solution of salt in water) were on Resident 26's bedside table and a medicine cup with white cream in it was on Resident 26's overbed table. Resident 26 stated she was itching in the weekend, and the licensed nurse gave the medicine cup with cream to her for itching. LVN D stated, the two bottles of NS and a cup with itching medication should not have been left in the room with the resident. During an interview with the DON on 10/13/23 at 2:49 p.m., she stated, the two bottles of NS and a cup with itching medication should not have been left in Resident 26's room. Review of the facility's policy, Storage of Medications, dated 4/2008, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. unlabeled, discontinued, and expired medications were not removed from the medication carts to prevent medication errors; 2. medications were not labeled with full names or open date; 3. an insulin glargine injection pen (medication to lower blood sugar) did not have a patient-specific label; 4. two bottles of normal saline, and a cup with itching medication were left inside the resident's room. These deficient practices had the potential for residents, to receive medications with unsafe and reduced potency, from using them past their discard date and medication errors due to medications not being labeled or removed from active stock. Findings: 1. During an inspection of medication cart one on 10/9/2023 at 12:40 p.m., with the Nurse Supervisor (NS), the NS confirmed the following findings: a) an Enoxaparin sodium (anticoagulant medication) injection 40mg (milligram, a unit of measurement of mass )/0.4ml (milliliter, a metric unit of volume) without label of resident information, b) a box of Aspercreme Lidocaine (pain medication) pain relief cream without label of resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 12 of 21 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 10/13/2023 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)

F 0761 information, Level of Harm - Minimal harm or potential for actual harm c) a box motion sickness medication labeled with only room number and the NS verified that this a discontinued medication for previous resident and Residents Affected - Some d) an insulin admelog solostar (medication for blood sugar) 100 unit/ml subcutaneous solution pen, open date 9/9/2023. The NS stated that the above medications should have been labeled with resident name, specific directions for use, strength of medication, and the insulin pen was good for 28 days after opening and expired on 10/7/2023. NS further stated, those medications should have been removed from the medication cart to prevent medication errors. 2. During an inspection of medication cart one on 10/9/2023 at 12:50 p.m., with the NS, the NS confirmed the following findings: a) two boxes of Brinonidine (eye medication) 0.2% eye drops for Resident 41 were not labeled with open date and the NS stated, those eye drops should have been discarded after 28 days of opening, b) a bottle of Systane (eye medication) 0.3-0.4 eyedrops long-lasting for dry eye relief for Resident 3 had no open date, c) a bottle of artificial tears for Resident 40 was not labeled with full name and no open date, d) an Icyhot Max (pain medication) no mess pain relief Lidocanine 4% roll-on for Resident 7 was labeled only with room number and last name and e) a bottle of women's daily multivitamins, 90 tablets for Resident 7 was labeled with only room number and last name. The NS stated those medications should have been labeled with full name and open date to prevent medication errors. 3. During an inspection of medication cart two on 10/9/2023 at 1:39 with NS, identified an insulin glargine injection pen was not labeled with resident information. The NS confirmed the insulin pen should have a patient-specific label to prevent mix-up with other residents' pens who had the same insulin orders. During an interview with the director of nursing (DON) on 10/9/2023 at 4:30 p.m., the DON stated, the insulin pen had been used for resident 17 for three days since 10/6/2023 and should have been labeled with patient-specific labeling and open date to prevent medication errors. A review of the 2017 Institute for Safe Medication Practices' (ISMP, a nonprofit patient safety organization with recognized national expertise in medication error prevention) Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults, indicated, If an institution chooses to use insulin pen devices, each should have contain a patient-specific label and be stored in a patient-specific bin/drawer . to prevent contamination from inadvertent misuse on another patient. A review of the facility's policy and procedure titled, Medication Ordering and Receiving From (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 13 of 21 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 10/13/2023 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Pharmacy: Medication Labels, Effective date, April 2014, indicated, .Each prescription medication label includes: resident's name, specific directions for use, including route of administration, medication name, expiration date of medication .nonprescription medication not labeled by the pharmacy are kept in the manufacturer's original container and identified with the resident's name . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 14 of 21 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 10/13/2023 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)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food palatability was maintained, when three of nine residents investigated, (Residents 3, 155 and 161), complained about the taste of the food being served. Residents Affected - Some This failure had the potential to result in decreased food intake and weight loss, compromising the resident's nutritional status. Findings: 1. During a concurrent observation and interview of Resident 3 on 10/9/23 at 11:30 a.m., Resident 3 was laying in her bed, alert, oriented, calm and comfortable. She's on oxygen inhalation (therapy that provides extra air to breathe in) at 2 liters per minute via nasal cannula (device used to deliver supplemental or air to a resident). Resident 3 stated that she did not like the food, it had no flavor or taste. She said that she told the dietary manager in training (DMIT) already about it but nothing was done. Review of Resident 3's clinical record indicated, Resident 3 was an [AGE] year-old female, admitted to the facility last 12/19/22, with diagnoses including, chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation (sudden worsening of symptoms), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and muscle weakness. Her brief interview for mental status (BIMS, cognitive screening measure that evaluates memory and orientation) score was 12, done on 8/10/23. Review of Resident 3's active orders as of 10/11/23, indicated, Resident 3 was on constant or controlled carbohydrate (CCHO) diet, regular texture, thin liquids consistency, low fat, chopped meat, cranberry juice with all meals, initiated on 10/10/23. During an interview with dietary manager (DM) on 10/12/23 at 10:42 a.m., DM verified that the reason, the food did not have taste to Resident 3, was because, they were not very specific in asking questions to Resident 3, about her food taste choice. DM further verified that she will do an in-service with her kitchen staffs about the proper way to ask residents, for their specific food taste choices. DMIT agreed with DM. 2. During a concurrent observation and interview of Resident 155 on 10/9/23 at 2:10 p.m., Resident 155 was laying in her bed, alert, oriented, calm and comfortable. She said that her food does not taste good or had no taste. Resident 155 further stated that the vegetables were either undercooked or overcooked and she told the staffs already about her concerns, but nothing was done. Review of Resident 155's clinical record indicated, Resident 155 was an [AGE] year-old female, admitted to the facility last 9/21/23, with diagnoses including, acute cystitis (infection of the bladder) without hematuria (blood in urine), COPD and difficulty in walking. Her BIMS score was 7, done on 9/26/23. Review of Resident 155's active orders as of 10/13/23, indicated, Resident 155 was on no added salt (NAS), regular texture, thin liquids consistency, fortified diet, initiated on 9/21/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 15 of 21 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 10/13/2023 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)

F 0804 Level of Harm - Minimal harm or potential for actual harm During an interview with DM on 10/12/23 at 10:55 a.m., DM verified that the reason, the food lack taste to Resident 155, was because, they were not very specific in asking questions to Resident 155, about her food taste choice and dislikes. DM further verified that she will do an in-service with her kitchen staffs about the proper way to ask residents, for their specific food taste choices and dislikes, so they can address the issue properly. DMIT agreed with DM. Residents Affected - Some 3. During a concurrent observation and interview of Resident 161 on 10/10/23 at 8:20 a.m., Resident 161, was laying in her bed, alert, oriented, weak but verbally responsive. She said that her food is not flavorful, and salty. Review of Resident 161's clinical record indicated, Resident 161 was a [AGE] year-old female, admitted to the facility last 10/6/23, with diagnoses including, hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (also known as stroke, refers to damage to tissues in the brain due to loss of oxygen to the area), affecting left non-dominant side, facial weakness and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Her BIMS score was 12, done on 10/11/23. Review of Resident 161's active orders as of 10/13/23, indicated, Resident 161 was on constant or controlled carbohydrate, no added salt diet, pureed texture, thin liquids consistency, low fat, low cholesterol, initiated on 10/6/23. During an interview with DM on 10/12/23 at 11:02 a.m., DM verified that the reason, the food did not have flavor to Resident 161, was because, they were not very specific in asking questions to Resident 161, about her food taste choice. DM further verified that she will do an in-service with her kitchen staffs about the proper way to ask residents, for their specific food taste choices, so they can address the issue properly. DMIT agreed with DM. During an observation and taste testing of sample lunch meal trays on 10/12/23 at 12:50 p.m., with DM, two lunch meal test trays were brought for taste testing. The first lunch meal test tray had regular lasagna and regular Italian green beans. The second lunch meal test tray had pureed lasagna and pureed Italian green beans. Tasted the regular lasagna, in the first lunch meal test tray and the regular lasagna tasted bland and did not have flavor at all. During an interview with DM on 10/12/23 at 12:52 p.m., DM acknowledged, after tasting also the regular lasagna that it tasted bland and did not have flavor. During the taste testing observation on 10/12/23 at 12:54 p.m., the regular Italian green beans in the first lunch meal test tray were then tasted and they had no flavor. They tasted bland. During an interview with DM on 10/12/23 at 12:55 p.m., DM acknowledged, after tasting the regular Italian green beans, that they tasted bland and did not have flavor. During the taste testing observation on 10/12/23 at 12:58 p.m., the pureed lasagna and pureed Italian green beans in the second lunch meal test tray were then tasted and they tasted ok. Review of the facility's policy and procedure titled, Food Preparation, dated 2023, indicated, Food shall be prepared by methods that conserve nutritive value, flavor and appearance. Prepared food will be sampled. The food and nutrition service employee who prepares the food will sample it to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 16 of 21 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 10/13/2023 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)

F 0804 Level of Harm - Minimal harm or potential for actual harm sure the food has a satisfactory flavor and consistency. Poorly prepared food will not be served. Such food is to either be improved, prepared again or replaced with an appropriate substitution. May add increased amounts of herbs and spices, not salt, since potency of products may vary. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 17 of 21 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 10/13/2023 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)

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 policy review, the facility failed to ensure food was stored in accordance with professional standards for food safety when: Residents Affected - Some 1. one 8-ounce water bottle brought by employee, was in Freezer #1; 2. one plastic bag with 7 frozen beef strips inside, had no used by date; and 3. the temperature of Refrigerator #2 was 50 degrees Fahrenheit (F, temperature scale). These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness for the 56 residents eating at the facility. Findings: 1. During an observation and interview with the dietary manager in training (DMIT) on 10/9/23 at 8:50 a.m., one 8-ounce water bottle brought by employee, was in Freezer #1. The DMIT stated that personal water bottle should have not put inside kitchen freezer. Review of the facility's undated policy, Employee meals, indicated, Policy: Food brought by employees from outside the facility should have not kept in the facility's refrigerator in the kitchen nor prepared or reheated in the facility's kitchen. Procedure: Employees bringing food from outside the facility may not keep their food in the refrigerator used to store food for the residents. 2. During an observation and interview with the dietary manager (DM) on 10/9/23 at 9:10 a.m., a plastic bag with 7 beef strips inside was in Freezer #3 and had no used-by date. The DM stated the plastic bag with 7 frozen beef strips should have been labeled with used-by date, and she should have thrown the bag away. Review of the facility's undated policy, Labeling and Dating of Foods, indicated, Newly opened food items would need to be closed and labeled with an open date and used by date. 3. During an observation and interview with the DM on 10/12/23 at 11:10 a.m., Refrigerator #2 had several cheese packs, juice boxes, milk containers, and a pan of cake inside, and the thermometer reading inside Refrigerator #2 was 50 degrees F. The DM stated that the refrigerator temperature should have been less than or equal to 41 degrees F, and she should have thrown the food items in Refrigerator #2 away. Review of the facility's undated policy, Cold Storage Temperature Monitoring and Record Keeping, indicated, Refrigerator temperature standards are less or equal to 41 F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 18 of 21 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 10/13/2023 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)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and policy review, the facility failed to follow its policy and procedure on foods brought by resident's family for two of fifteen residents (11 and 21), when an expired 8-ounce bottle of Glucerna (a nutritional supplement) and an expired box of sesame cookie rolls were on Resident 11's and Resident 21's night stands. These failures had the potential to result, for Resident 11 and Resident 21, to develop foodborne illness. Residents Affected - Few Findings: During an observation and interview with licensed vocational nurse B (LVN B) on 10/9/23 at 12:03 p.m., an 8-ounce bottle of Glucerna was found on top of Resident 11's night stand with an expiration date of 7/1/23. LVN B stated, the Glucerna bottle had already expired, and it should have not kept inside the resident room. During an interview with the director of nursing (DON) on 10/13/23 at 2:34 p.m., she stated the expired Glucerna bottle should have not in Resident 11's room on her night stand even though it was brought in by Resident 11's family. During an observation and interview with LVN B on 10/9/23 at 12:24 p.m., a box of sesame cookie rolls was found on top of Resident 21's night stand with an expiration date of 3/23/22. LVN B stated, the box of sesame cookie rolls had already expired, and it should have not kept inside the resident room. During an interview with the DON on 10/13/23 at 3:08 p.m., she stated the box of sesame cookie rolls was expired, and it should have not kept with Resident 21 on her night stand. Review of the facility's policy, Foods Brought by Family/Visitors, dated 10/2017, indicated, . 9. The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 19 of 21 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 10/13/2023 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident 20's admission Record indicated he was admitted to the facility on [DATE] with acute respiratory failure diagnosis. Residents Affected - Some Review of Resident 20's physician order, dated 8/23/23, indicated he had an order for oxygen (therapy that provides extra air to breathe in) at 2 liters (L, a metric unit of volume) per minute via nasal cannula (device used to deliver supplemental or air to a resident) continuously every shift. During an observation and interview with licensed vocational nurse B (LVN B) , on 10/9/23 at 11:44 a.m., Resident 20 was lying in bed and was on oxygen. However, the filter of the oxygen concentrator was dusty. There was a layer of dust in the filter. LVN B stated, the filter of Resident 20's oxygen concentrator should have been cleaned. During an interview with the director of staff development (DSD), on 10/13/23 at 2:13 p.m., she stated, the filter of the oxygen concentrator should have been cleansed every week. Review of the facility's undated oxygen concentrator Patient Manual, indicated Cleaning the air inlet filter was the most important maintenance activity that you would perform and should have been done at least once a week. 4. During an observation on 10/11/23 at 11:06 a.m., certified nursing assistant C (CNA C) walked out of Resident 26's room with gloves on her hands. During a concurrent interview with CNA C, she stated, she just helped Resident 26, and she should have removed her gloves before exiting Resident 26's room. During an interview with the DSD on 10/13/23 at 2:12 p.m., she stated the staff should have removed the gloves before exiting the residents' room. Review of the facility's policy, Personal Protective Equipment - Gloves, dated 7/2009, indicated, Gloves should have been used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed. Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for five of fifteen sampled residents (Residents 16,18, 161, 20, and 26) when: 1. Resident 16 and 18, the licensed nurses did not perform hand hygiene between glove changes during medication administration, 2. Resident 161, the licensed nurse did not disinfect the medication tray after touching potentially contaminated surfaces, 3. Resident 20, the filter of the oxygen concentrator was dusty and 4. for Resident 26, Certified Nursing Assistant C (CNA C) walked out of Resident 26's room with gloves on her hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 20 of 21 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 10/13/2023 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some These failures could result in the spread of infection and cross-contamination that could affect the 61 residents in the facility. Findings: 1. During a medication administration observation on 10/11/2023 at 11:45 a.m., with licensed vocational nurse LVN A in front of Resident 16's room, LVN A was observed performing multitask and changing gloves between tasks but did not wash or sanitize her hands between glove changes. During an interview with LVN A on 10/11/2023 at 11:50 a.m., LVN A acknowledged she did not perform hand hygiene between glove changes. LVN A stated she should have sanitized her hands between glove changes to prevent spreading infections. During a percutaneous endoscopic gastrostomy (PEG, a feeding tube that is placed into a patient's stomach) tube dressing change observation on 10/12/2023 at 10:20 a.m., at Resident 18's bedside, the treatment nurse (TN) was observed performing multitask by removing old dressing, cleaning the PEG tube area, and placing new dressing with different new pairs of gloves but did not perform hand hygiene between glove changing. During an interview with the treatment nurse on 10/13/2023 at 8:47 a.m., the TN acknowledged she should have sanitized her hands between changing gloves, and during dressing change. A review of the facility's policy and procedure titled Hand Washing /Hand Hygiene, Revised 6/2021, indicated, Use an alcohol-based hand rub containing at least 62% alcohol; alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .after removing gloves . 2. During a medication administration observation on 10/11/2023 at 12:07 p.m. with licensed vocational nurse (LVN F) in Resident 161's room., LVN F was observed placing the medication tray on Resident 161's bed and then placing it on Resident 161's lunch tray without disinfection in between. During an interview with LVN F on 10/11/2023 at 12:15 p.m., LVN F acknowledged he should have not placed the medication tray on Resident 16's bed and moved it to her lunch tray without disinfecting it. During an interview with the director of nursing (DON) on 10/13/2023 at 2:00 p.m., the DON stated staff should have perform hand hygiene between glove changes and disinfect resident care items or medicinal equipment after touching potentially contaminated surfaces to prevent infections. A review of the facility's policy and procedure titled Cleaning and Disinfection of Resident-care items and Equipment, Revised October 2018, indicated, .Reusable items are cleaned and disinfected or sterilized between residents . single resident-use items are cleaned/disinfected between uses . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 21 of 21