Health inspection·December 11, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow it's Policy and Procedure titled Isolation-Categories of Transmission- Based Precautions, when the facility failed to provide evidence of implementing isolation precautions (process of creating barriers between people and germs to help prevent the spread of infectious microbes) during an outbreak of infectious gastrointestinal related illnesses for four of six sampled residents (Resident 1, Resident 2, Resident 3 & Resident 4). This failure had the potential to spread infectious disease to other residents and staff at the facility. Residents Affected - Some Findings: During an interview on 12/2/24, at 9:35 a.m., with Infection Prevention Nurse (IP), IP stated, the care staff reported multiple residents with vomiting and diarrhea during the night shift in early October. IP stated, she became aware of the outbreak because it was documented in a change of condition report. IP stated, they began testing residents for C-diff (Clostridium difficile a bacterium that causes an infection of the colon, spread through physical contact) and Norovirus (viral infection causing vomiting and diarrhea spread through physical contact). IP stated, their procedure for isolation precautions are, once the staff identify symptoms of an infectious disease, they notify charge nurse who will place orders and notify the doctor, and put in orders for isolation precautions, in this case we would put the order for contact precautions (Use of personal protective equipment (PPE) appropriately, including gloves and gown). The IP stated, either herself or the charge nurse would put up isolation precaution signs outside the residents room to inform staff and visitors. During a review of the IP's outbreak documentation spreadsheet (an excel spreadsheet of all persons involved in the outbreak), undated, the spreadsheet indicated, 23 residents had GI related symptoms (ranging from nausea, vomiting, diarrhea, fever, or abdominal cramping) from the date range 10/18-10/30/24. The spreadsheet indicated, 11 staff members had GI related symptoms from the date range 10/22-10/27/24. The spreadsheet indicated, 6 residents were tested positive for norovirus in this date range, and one for c-diff. During a review of Resident 1's Change in Condition Evaluation(CIC) dated 10/22/24, CIC indicated, Nausea/Vomiting reported by staff during the night. During a concurrent interview and record review on 12/2/24, at 11:04 a.m., with IP, Resident 1's MD orders dated 10/22/24-10/28/24 was reviewed. MD orders indicated, no order for isolation precautions. IP stated Resident 1 should have been placed on isolation during the outbreak. During a review of Resident 1's MD orders dated 10/23/24, MD order indicated, collect stool culture for norovirus. (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 12/11/2024 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)