Health inspection·February 12, 2025

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and document review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) for 1 (Resident #51) of 2 sampled residents reviewed for nutrition. Residents Affected - Few Findings included: The Centers for Medicare & Medicaid Services Long -Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual dated 10/2024, indicated, 03. Significant Change in Status Assessment The SCSA is a comprehensive assessment for a resident that must be completed when the IDT [interdisciplinary team] has determined that a resident meets the significant change guidelines for either major improvement or decline. Per the manual, A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Required interdisciplinary review and/or revision of the care plan. According to the manual, a Decline in two or more of the following: included Any decline an ADL [activity of daily living] physical functioning area where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individual's functioning; and Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days). An admission Record indicated the facility admitted Resident #51 on 06/26/2024. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease, dementia, need for personal assistance, and dysphagia (difficulty swallowing). A quarterly MDS, with an Assessment Reference Date (ARD) of 09/26/2024, revealed Resident #51 was severely impaired in cognitive skills for daily decision making. The MDS indicated the resident required substantial/maximal assistance with eating and oral hygiene. Per the MDS, the resident weighed 125 pounds and did not have any weight loss. A quarterly MDS, with an ARD of 12/19/2024, revealed Resident #51 was severely impaired in cognitive skills for daily decision making. The MDS indicated the resident was dependent on staff for eating and oral hygiene. Per the MDS, the resident weighed 115 pounds and had weight loss of 5% or more in the last month or 10% or more in the last six months. Resident #51's care plan, included a focus area initiated 06/26/2024 and revised 07/11/2024, that indicated the resident had impaired nutritional and hydration status. Interventions directed staff to refer the resident to the registered dietician and/or the interdisciplinary team for significant (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 02/12/2025 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)