Health inspection·January 27, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain a complete medical record for one of three sampled residents (Resident 1) when: 1. The facility treated a wound to Resident 1's coccyx (tailbone) that was present upon admission, but did not document that they obtained a physician's order for wound treatment until eight days after admission; 2. The facility did not document treatments of Resident 1's coccyx wound until eight days after admission; and, 3. There was one week during which the facility did not document the assessment of Resident 1's coccyx wound. These failures had the potential to compromise the facility's ability to ensure Resident 1's wound was treated and monitored. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had diagnoses including overactive bladder (a condition that causes the sudden urge to urinate) and enterocolitis due to clostridium difficile (inflammation of the intestines that causes watery stools). Review of Resident 1's nursing admission assessment, dated 10/3/24, indicated Resident 1 had non blanchable redness (redness that does not turn white when pressed) with open skin on the coccyx. During an interview with Resident 1's family member (FM) on 1/24/25 at 3:10 p.m., the FM confirmed Resident 1's coccyx wound was present upon admission. The FM explained that once the facility saw the wound was present, they implemented routine wound treatments. During an interview and concurrent record review with the wound treatment nurse (WTN) on 1/27/25 at 9:55 a.m., the WTN explained that if a resident has a wound upon admission, the admitting nurse should obtain a physician's order for wound treatment, and the wound treatments should be documented on the treatment administration record (TAR). The WTN further explained that for residents with wounds, there should be wound assessments documented in the medical record weekly. The WTN reviewed Resident 1's medical record and confirmed the resident had a coccyx wound upon admission. The WTN confirmed there was no documentation that the facility obtained a wound treatment order, and no (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: 055798 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 055798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vasona Creek Healthcare Center 16412 Los Gatos Boulevard 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)