Health inspection·August 6, 2021

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete clinically appropriate and safe for the residents to do so. The staff will assess each resident's mental and physical abilities to determine whether self administering medications is clinically appropriate for the resident. If the team determines a resident can not safely administer medications, the nursing staff will administer the resident's medications. A review of the facility's October 2017 policy,Medication Administration-General Guidelines, indicated residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Event ID: Facility ID: 055800 If continuation sheet Page 2 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 make appropriate referral for Level II preadmission screening and resident review (PASRR, a comprehensive evaluation conducted by a state-designated authority that determines whether an individual has a mental disorder (MD), intellectual disability (ID), or a related condition as defined above, determines the appropriate setting for the individual, and recommends what, if any, specialized services and/or rehabilitative services the individual needs), for one of 15 sampled residents (Resident 4). This failure may lead to denying specialized services and rehabilitation services available for Resident 4 and may limit her capacity to reach their highest mental, physical, and psychosocial well-being. Residents Affected - Few Findings: Review of Resident 4's facesheet included diagnoses of anxiety disorder (a mental health disorder characterized by feelings of worry, fear, or anxiety strong enough to interfere with daily activities) and major depressive disorder (a mental health disorder characterized by persistent loss of interest in activities causing significant impairment in daily life). During a record review and concurrent interview on 8/4/21 at 12:12 p.m., minimum data set nurse B (MDSN B) reviewed Resident 4's PASARR completed on 4/12/21 that indicated Section V (Mental Illness) item 27 with missing response, and item 29 with incorrect response. MDSN D concurred if these two items were correctly coded it would require Level II PASARR evaluation. MDSN B also stated she missed coding the items correctly that would require Level II evaluation by the Department of Health Care Services. Review of the facility's 12/2017 revised policy, ASPEN SKILLED HEALTH POLICY-PAS/PASSARR, indicated every medical recipient admitted to a skilled nursing facility is subject to [NAME] Level I & Level II screening or evaluation upon admission. Any resident identified with DD or MI medical conditions upon admission must be referred for a Level II evaluation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 3 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to implement the care plan (provides direction on the type of nursing care the individual may need) to monitor intake and output (I &O) for one of 15 sampled residents (Resident 44) who had a jejunotomy tube (JT, a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine used for administration of food and medications). This failure had the potential to result in the inability to identify the resident's hydration status/needs. Findings: During the facility's initial tour on 8/2/21 at 11:49 a.m., Resident 44 was sitting in bed with tube feeding (TF) disconnected. Resident 44 stated she could also take food and fluids by mouth. Review of Resident 44's clinical record indicated she had a physician's order of Fibersource HN (formula) 40 ml (milliliter, unit of measurement) per /hour for 12 hours, on at 9:00 p.m. and off at 9:00 a.m. Flush JT with 150 ml. water every shift. Flush with 30 ml before and after medication. During a record review and concurrent interview with the assistant director of nursing (ADON) on 8/4/21 at 3:27 p.m., Resident TF care plan included monitor intake and output. The ADON reviewed Resident 44's intake and output monitoring that indicated multiple missing entries of the intake and output every shift and daily total, and weekly assessments from 6/10/21 to 8/3/21. A review of the facility's 10/12/2020 revised policy and procedure, Intake and Output, indicated it is the policy of this facility to maintain an intake and output record when needed to monitor residents for adequate fluid balance. The licensed nurse shall document resident's intake and output at the end of each shift on the intake and output record. The total intake and output during each 24-hour period shall be totaled by the designated licensed nurse. Weekly assessments will be done by the licensed nurse to determine the on-going need for I and O monitoring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 4 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice when: Residents Affected - Some 1. For Resident 201, the daily weight and the fluid restriction orders were not followed; 2. For Resident 204 the PICC line external catheter length was not measured during each dressing change and flushes were not performed; 3. For Resident 217, dressing changes and flushes were not performed for the PICC line; 4. For Resident 2, physician order for left arm sling use was not followed; 5. For Resident 249, the PICC line external catheter was not measured upon admission and during dressing change; 6. For Resident 46, the left hemi arm tray use was not followed. 7. For Residents 5, 13 and 149, the nurses did not check the residents' heart rate (HR) prior to the medication administration 8. For Resident 10, the LVN did not check the right medication, dose and time and resident's ID (identification) before medication adminsitration. 9. For Resident 13, one dose of medication was not administered. For Resident 5, medication administration with meals was not followed. These failures had the potential to compromise the residents' health and well-being. Findings: 1. Review of Resident 201's clinical record indicated he was admitted to the facility on [DATE]. A physician order, dated 7/29/21 indicated daily weights in the morning and to call the physician if greater than a 2 pound gain. Review of the daily weight record for Resident 201 indicated the resident was weighed on 7/29/21, 7/30/21 and 8/3/21. There were no weights recorded for Resident 201 on 7/31/21, 8/1/21, or 8/2/21. During an interview and concurrent record review with the assistant director of nursing (ADON) on 8/3/21 at 2:20 p.m., she stated Resident 201 had a physician order to be weighed daily in the morning. She confirmed there were three consecutive days when Resident 201's weight was not recorded. The ADON stated the physician orders should be followed and the resident should be weighed daily. Review of Resident 201's clinical record indicated a physician order, dated 7/29/21, for a fluid restriction of 1.5L (liter- a unit of measure, 1 liter = 1000 cubic centimeters [cc, - a unit of measure]) per day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 5 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 Residents Affected - Some During an observation on 8/3/21 at 7:58 a.m., Resident 201 had a water pitcher filled with cold water and a plastic cup on his bedside table. During a concurrent interview with certified nursing assistant F (CNA F) she confirmed that Resident 201 had a water pitcher at his bedside. CNA F stated she was not aware that Resident 201 had any fluid restrictions. During an interview with the registered dietician (RD) on 8/3/21 at 9:00 a.m., she confirmed Resident 201 was on a fluid restriction of 1.5L. She stated she calculated the fluid allotments for the kitchen and nursing staff and recorded the breakdown on the Fluid Restriction document she placed in Resident 201's clinical record. The RD indicated a total of 960 cc of fluids was allowed for the daily kitchen tray services and 540 cc of fluid was allowed for nursing during a 24 hour period. Review of Resident 201's intake and output record indicated 24 hour totals of fluid intake provided and recorded by the nursing staff. On 7/30/21 Resident 201's 24 hour fluid intake was 1060 cc. On 7/31/21 Resident 201's 24 hour fluid intake was 980 cc. On 8/1/21 Resident 201's 24 hour fluid intake was 710 cc. On 8/2/21 Resident 201's 24 hour fluid intake was 1320 cc. The 24 hour nursing fluid allotment as stated by the RD was 540 cc. During an interview with registered nurse E (RN E) on 8/3/21 at 8:45 a.m., she confirmed Resident 201 was on a fluid restriction and stated she usually gave him 180 cc during the night shift. She further stated that she could not give Resident 201 more than 200 cc during her shift. The Fluid Restriction document indicated the fluid allotment for Resident 201 during the night shift was 60 cc. During an interview with RN D on 8/3/21 at 10:15 a.m., she confirmed Resident 201 was on a fluid restriction. She further stated Resident 201 received a total of 600 cc during the day shift. The Fluid Restriction document indicated the fluid allotment for Resident 201 during the day shift was 240 cc. During an interview with the director of nursing (DON) on 8/5/21 at 9:30 a.m. she confirmed the nursing staff was not following the prescribed fluid restrictions for Resident 201. She further stated all staff should be aware when residents have a fluid restriction. The DON stated the fluids allotments should be followed by the nursing staff. Review of the facility's policy, Encouraging and Restricting Fluids revised October 2010, indicated to follow specific instructions concerning fluid intake or restrictions and to be accurate when recording fluid intake. When a resident has been placed on restricted fluids, remove the water pitcher and cup from the room. 2. During an observation on 8/2/21 at 10:15 a.m., Resident 204 had a peripherally inserted central catheter (PICC, a thin, soft, long catheter [tube] that is inserted into a vein in arm, leg or neck and the tip of the catheter is positioned in a large vein that carries blood into the heart) line. The PICC line was located on her right upper arm with a transparent dressing dated 7/29/21. Review of Resident 204's clinical record indicated she was admitted to the facility on [DATE] with a PICC line on her right upper arm and was to receive intravenous antibiotic therapy three times a day until 8/3/21. Review of Resident 204's Order Summary Report indicated an order dated 7/29/21, to flush PICC line lumens with 10 milliliter (ml, unit of measure) of normal saline before and after IV (intravenous) medication administration every shift. Resident 204's clinical record indicated intravenous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 6 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 Residents Affected - Some antibiotic therapy started on 7/23/21. There was no physician order or documentation to indicate Resident 204's PICC line was flushed until 7/29/21. Review of Resident 204's medication administration record indicated a PICC line dressing changed was performed on 7/29/21. The documentation recorded the nurse's initials but did not include a recorded length measurement of the PICC line's external catheter. During an interview and concurrent with registered nurse D (RN D) on 08/03/21 at 11:50 a.m., she confirmed she changed Resident 204's PICC line dressing on 7/29/21 but did not record the length of the external catheter. RN D further stated the length should be recorded to monitor for movement or dislodgment of the PICC line catheter. During an interview with the director of nursing (DON) on 8/5/21 at 9:30 a.m., she indicated a physician order is required to flush a catheter and the order must include the flushing agent, strength, volume and frequency. The DON confirmed flushing of PICC lines should be done before and after intravenous medication administration and documented in the clinical record. The DON indicated the length of the PICC line external catheter should be measured and recorded during each dressing change. She further stated that PICC line dressings should be changed every 7 days. 3. During an observation on 8/2/21 at 9:48 a.m., Resident 217 had a PICC line located on his left upper arm with a transparent dressing dated 8/1/21. Review of Resident 217's clinical record indicated he was admitted to the facility on [DATE] with a PICC line on his left upper arm and was to receive intravenous antibiotic therapy two times a day until 8/22/21. Review of Resident 217's Order Summary Report indicated an order dated 7/16/21, for Vancomycin HCL solution (antibiotic) one gram intravenously two times a day. There was no physician order for the month of July to flush the PICC line before and after intravenous therapy, and no documentation that PICC line dressing changes were done during the month of July. During an interview and concurrent record review with the director of nursing (DON) on 8/5/21 at 9:30 a.m., she confirmed Resident 217 received intravenous therapy during the month of July. She stated there was no evidence that flushes and dressing changes for Resident 217's PICC line were performed during the month of July. The DON further stated resident's PICC line dressings should be changed once a week and there should be physician orders for flushing before and after intravenous medication administration Review of the facility's policy, PICC Dressing Change dated June 2018, indicated dressing changes using transparent dressings are performed upon admission and at least weekly. The length of external catheter is obtained upon admission and during dressing changes. Review of the facility's policy, PICC Flushing dated June 2018, indicated flushing is performed to ensure and maintain catheter patency. Documentation in the medical record includes date and time, prescribed flushing agent, and site assessment. 4. Review of Resident 2's clinical record indicated she was admitted to the facility with diagnoses including fracture of non-displaced surgical neck of left humerus (broken left shoulder bone). Review of the admission Minimum Data Set (MDS, resident's assessment) dated 7/17/21, indicated that Resident 2's Brief Interview for Mental Status (BIMS, a set of questions to test a person's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 7 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 cognition) score is 15 ( Resident 2 is cognitively intact). Level of Harm - Minimal harm or potential for actual harm During observation on 8/02/21 at 2:55 p.m. inside the bedroom, Resident 2 was lying flat on the bed, wearing a facility gown, and no left arm sling. Residents Affected - Some During a concurrent observation and interview on 8/4/21 at 10:26 a.m., with Resident 2, inside the bedroom, Resident 2 was lying flat in bed with oxygen, no sling to the left arm. Resident 2 stated, I don't think I need it. Resident 2 added, I never wear it and I don't even have it. During an interview 8/04/21 at 2:02 p.m. with registered nurse L (RN L), stated that she's not aware about the left arm sling order. During a concurrent interview and record review, on 8/5/21 at 1:25 p.m. with the occupational therapist (OT), Resident 2's physician order dated 7/11/21 indicated to apply sling to left arm due to left shoulder fracture (broken bone) every shift. OT stated that the order has been changed since Resident 2 had a follow-up appointment with the orthopedic surgeon (doctor that specializes in bones) on 7/22/21. The physician order on 7/22/21 indicated No directions specified for order. OT confirmed that the order for the use of left arm sling is still the same 5. During an observation on 8/2/21, in 12:41 p.m., at Resident 249's room, the resident was lying in bed. Resident's PICC line located on her left upper arm was intact, with the insertion site covered with a transparent dressing. The date on the dressing was 7/29/21. Review of Resident 249's clinical record indicated she was admitted to the facility on [DATE]. The resident is on IV antibiotics for diagnosis of Right Knee Prosthetic Joint Infection. Review of Resident 249's Care Plan, date initiated 7/27/21, indicated, Flushes and site care per facility protocol. Review of the facility's policy, dated 6/2018, PICC Dressing Change, indicated, length of external catheter is obtained: 1. Upon admission 2. During dressing changes 3. If signs or symptoms of complications are present. During an interview and brief record review with RN L on 8/6/21, at 1:15 p.m., upon review of the Treatment Administration Record (TAR) and nurse's notes, there was no record that the length of the PICC line's external catheter was obtained upon admission and during dressing changed on 7/29/21 per policy. 6. During an observation on 8/2/21, at 11:35 a.m., Resident 46 was outside of her room, seated in her wheelchair. The left hemi arm tray was attached to her wheelchair. During observations on 8/3/21, at 12:15 p.m. and 2:00 p.m., Resident 46 was in the hallway seated in her wheelchair. The surveyor observed the left hemi arm tray was no longer attached to the wheelchair. Review of Resident 46's, Order Summary Report, indicated, Left hemi arm tray while up in wheelchair for positioning and comfort. Review of Resident 46's, Care Plan, initiated 7/26/18, indicated, Left hemi arm tray to support (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 8 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 left weak arm. Level of Harm - Minimal harm or potential for actual harm Review of Resident 46's Clinical Record, indicated, Resident 46 was admitted on [DATE], with a primary diagnosis of hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (stroke, damage to tissues in the brain) affecting left dominant side. Residents Affected - Some During an interview and brief record review with the ADON on 8/4/21, at 3:05 p.m., ADON was made aware of the above observation. ADON confirmed there was no documentation of refusal of Resident 46's left hemi arm tray. ADON said that she will inform the physician of the resident's refusal. She further stated that monitoring of the resident's episodes of refusal will be initiated. 7. During the medication pass observation on 8/2/21 at 3:47 p.m., licensed vocational nurse C (LVN C) did not check Resident 13's heart rate (HR) before administering Carvedilol (medication to lower blood pressure, and heart failure that could also lower HR) 12.5 mg. (milligrams, unit of measurement) 1 tablet by mouth. A review of Resident 13's active physician's order indicated Carvedilol 12.5 mg tab, hold for SBP(systolic blood pressure, the top number, measures the force your heart exerts on the walls of your arteries each time it beats) < (less than) 120, HR <60. His MAR dated 8/1/21 indicated the Carvedilol 12.5 mg 1 tablet was not administered on 8/1/21 at 5:00 p.m. During the medication pass observation on 8/2/21 at 4:23 p.m., Resident 10 who was the hallway in her wheelchair requested LVN C for her medications. LVN C administered Resident 10's medications without checking the medication administration record (MAR) for correct medication, dose and time, and Resident 10's identification (ID). During the medication pass observation with licensed vocational nurse D (LVN D) on 8/3/21 at 8:20 a.m., LVN D did not check Resident 5's HR prior to the administration of Metoprolol tartrate (betablocker, medication that slows down heart rate and makes it easier for the heart to pump blood) 25 mg. one tablet by mouth and Isosorbide Mononitrate (medication that dilates [widens] blood vessels, making it easier for blood to flow) 20 mg. one tablet by mouth. During the follow up interview and medication reconciliation done on 8/3/21 at 11:15 a.m., LVN D confirmed he did not check Resident 5's HR and stated he should have checked the resident's HR before administration of the medications. During the medication pass observation on 8/4/21 at 4:31 p.m., registered nurse E (RN E) did not check Resident 149's HR before she administered the Carvedilol 6.25 mg one tablet. During a follow-up interview with RN E, she confirmed she did not check Resident 149's HR prior to giving the medications. A review of Resident 149's physician's orders dated 7/22/21 included Carvedilol 6.25 mg. 1 tablet by mouth two times a day for hypertension (elevated blood pressure), hold for SBP <100 or HR <60; and Isosorbide Dinitrate (dilates the blood vessels) 40 mg by mouth three times a day for HTN, hold for SBP<100 or HR <60. 8. During the medication pass observation on 8/2/21 at 4:23 p.m., Resident 10, who was the hallway in her wheelchair, requested LVN C for her medications. LVN C administered Resident 10's medications without checking the medication administration record (MAR) for correct medication, dose and time, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 9 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 and Resident 10's identification (ID). During the follow-up interview and record review, LVN confirmed she gave Resident 10 her scheduled Pantoprazole (used to treat certain stomach and esophagus problems such as acid reflux by decreasing the amount of acid stomach produces) and Magnesium Oxide (dietary supplement medications used to treat constipation, indigestion, and headaches) without checking the medication administration record (MAR) and resident's identification (ID). Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 10 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement interventions to prevent falls for one of 12 sampled residents (Resident 4). The minimum data set (MDS, an assessment tool) did not accurately code the fall incident that resulted in an injury that required hospital transfer for evaluation and treatment. This failure could have resulted in a fall with possible injury without the surveyor's intervention by calling staff's immediate attention to the situation. Findings: 1. Review of Resident 4's face sheet indicated he was admitted [DATE] with diagnoses that included spinal stenosis (a narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine), weakness, difficulty walking, muscle wasting and atrophy (loss of muscle mass due to the muscles weakening and shrinking). His MDS dated [DATE] indicated a brief interview for mental status (BIMS, assessment for cognition) score of 5 or severely impaired cognition. Resident 4 had a history of three unwitnessed fall incidents on 12/10/2020, 1/6/21and 1/12/21. The unwitnessed fall incident that happened on 12/10/2020 indicated the resident was found lying on his left side at bedside, not responding to verbal and barely open eyes on tactile (touch), and was sent to hospital via 911(emergency call that requires immediate assistance from the police, fire department or ambulance). During a record review and concurrent interview on 8/4/21 at 11:09 a.m., minimum data set nurse B (MDSN B) reviewed Resident 4's MDS dated [DATE] Section J1900 that indicated he had no injury after the fall. MDSN B concurred the coding was not correct and should code the fall with major injury due to loss of consciousness/unresponsiveness that resulted in staff calling 911 and he was sent to the hospital. MDSN B gave a copy of the corrected MDS done on 8/4/21. Resident 4 had a care plan dated 4/12/21, indicating High risk for falls and injury related to Limitation of mobility, History of Fall(s), and interventions included sensor pad alarm (equipment placed in bed or wheelchair that sets off alarm when pressure is off the device) when in bed and up in wheelchair to alert the staff when the resident is attempting to get out of bed unassisted. During an observation on 8/4/21 at 11:15 a.m., when the surveyor went inside resident room [ROOM NUMBER], Resident 4 was on the farthest left side of the bed with both legs up and almost on the ground trying to remove his diaper. He had a bowel movement (stools in the diaper). The surveyor told the resident not to move because he would fall and immediately called for staff's help. Licensed vocational nurse J (LVN J) came right away and assisted the resident. At that time, the pad sensor alarm did not sound off. Certified nursing assistant K (CNA K) came to the resident's room to help. In the presence of LVN J, CNA K checked the bed sensor pad alarm multiple times but the alarm did not sound. The wheelchair that the resident used just before he was seen in bed did not have the sensor pad as well. During an interview on 8/4/21 at 11:45 a.m., CNA G (CNA G) stated Resident 4 was in his wheelchair (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 11 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in the dining room before she left for her break at 11:05 a.m. and he was able to wheel and put himself back to bed. CNA G admitted she did not place the sensor pad alarm in the wheelchair before putting the resident in the wheelchair. During a follow-up interview and record review on 8/4/21 at 11:45 a.m., the assistant director of nursing (ADON) stated she kept the chair sensor pad inside Resident 4's drawer a couple of days prior and noted that the sensor pad was still there when this incident happened, so was not applied to the wheelchair. The ADON also stated she already brought the bed sensor pad for maintenance to fix. The ADON claimed she just conducted a bedside in-service for her staff. The ADON reviewed Resident 4's care plan and confirmed the care plan included sensor pad alarm for bed and chair. During an interview on 8/4/21 at 1:38 p.m., LVN J stated he did not check Resident 4's sensor alarm and concurred the resident could have fallen without the surveyor's intervention. A review of the revised September 2010 policy and procedure, Resident Assessment Instrument, indicated information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. A review of the revised March 2018 policy and procedure, Managing Falls and fall Risk indicated the staff will identify interventions to prevent resident from falling and minimize complications from falling. Position alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff would respond to alarms in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 12 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when: Residents Affected - Few 1. Discontinued controlled medications for multiple discharged residents were not removed timely from one of two medication carts (Med Cart #1) to prevent medication errors and potential for loss and misuse; and 2. The random controlled medication use audit for one resident (Resident 208) did not reconcile. The medication signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) was not consistent with the amount taken and administered to Resident 208. This failure had the potential for misuse or diversion of controlled medications. Findings: 1. During an inspection for Medication Cart #1 with registered nurse D (RN D) on 8/2/21 at 12:30 p.m., a locked compartment containing controlled medications was identified. It contained medications for current residents as well as for discharged residents. Review of the contents inside revealed multiple blister cards (bubble pack a pharmacy-prepared paperboard with medications in individual doses that can be punched out of the card when administered) of controlled medications. RN D stated controlled medications of discharged /hospitalized residents should be removed from the medication cart and should be given to the director of nursing (DON) soon after the resident's discharge. 2. During the inspection of the Medication Cart #1 with RN D on 8/2/21 at 12:30 p.m., there was one tablet of Hydrocodone -APAP (pain medication) 5-325 mg. one tablet remaining in the bubble pack. The CDR indicated there should be two remaining tablets. During the concurrent interview and record review with RN D, Resident 5's MAR indicated she was administered two tablets of Hydrocodone-APAP. RN D stated she signed out one tablet instead of two in the CDR. RN D also stated anytime a controlled drug was taken out it should be signed out right away. During an interview on 8/6/21 at 2:24 p.m. with the director of nursing (DON), she said if medications were discontinued the nurse should remove them from the cart and give to the DON, for disposal and destruction with the pharmacist. A review of the facility's April 2008 policy and procedure, Controlled Medications, indicated Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subjected to special handling, storage, disposal, and record keeping in the facility. The Director of Nursing and the consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. When a controlled medication is administered, the licensed nurse administering the medication immediately enters in the accountability record the date and time of administration, amount administered and the signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 13 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview, and record review, the facility failed to ensure the pharmacy consultant's identified and reported drug irregularities to the attending physician and the facility's medical director and director of nursing, for 2 of 15 sampled residents (Residents 8 and 12). This failure could result in the continued use of unnecessary psychotropic medications for the two residents. A review of Resident 8's physician order dated 2/26/21 indicated Remeron 7.5 milligram (mg, unit of measurement) one tablet by mouth at bedtime for depression as manifested by poor appetite. Her monthly Psychotropic Summary and monitoring of the number behavior episodes were not done. A review of Resident 12's physician's order dated 7/27/2020 indicated Remeron 15 mg. one tablet by mouth at bedtime for depression manifested by poor appetite. Her Psychotropic Summary for Remeron's behavior manifestation of poor appetite from July 2020 to July 2021 did not clearly indicate the number of episodes of poor appetite. A review of the Pharmacy Consultant's Monthly Drug Regimen Review from January to July 2021 did not have any documented evidence that Residents 8 and 12's behavior monitoring of poor appetite and missing monthly Psychotropic Summary were reported to the facility, and the GDR for their Remeron use was recommended. During an interview on 8/6/21 at 9:52 a.m., the pharmacy consultant (PC) reviewed Resident 8 and 12's clinical record and confirmed that GDR for their Remeron use were not done. The PC stated GDR should be done twice on the first year of use. The PC also concurred the monitoring for poor appetite for Residents 8 and 12 should have been individualized and quantified to clearly identify the number of episodes and what indicated a poor appetite for each one. The PC admitted having missed informing and following-up with the facility to verify poor appetite for both residents and to complete their monthy behavior summary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 14 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic drugs (medications that are capable of affecting the mind, emotions, and behavior) for three of 15 sampled residents (Residents 8 and 12) when: There was no accurate behavior monitoring, monthly behavior summary, and GDR (gradual dose reduction) for Residents 8 and 12's Remeron (antidepressant) use. There was no psychotic and hypnotic assessment completed when Resident 12 had significant change of condition. These failures resulted in the unnecessary drugs use for these residents. Findings: A review of Resident 8's physician order dated 2/26/21 indicated Remeron 7.5 milligram (mg, unit of measurement) one tablet by mouth at bedtime for depression as manifested by poor appetite. A review of Resident 12's physician's order dated 7/27/2020 indicated Remeron 15 mg. one tablet by mouth at bedtime for depression manifested by poor appetite. During a record review and concurrent interview on 8/4/21 at 10:03 a.m., minimum data set nurse I (MDSN) reviewed Resident 12's clinical record that indicated she had a significant change done on 5/22/21 and the Psychotropic and Hypnotic Assessment should have been done. MDSN I stated, I must have missed. During an interview and concurrent record review on 8/6/21 at 8:32 a.m., the assistant director of nursing (ADON) could not find any documented evidence that Resident 8's monthly psychotropic behavior summary and the monitoring of the number of episodes for poor appetite were done. Review of the resident's meal percentage from April 2021 to July 2021 indicated the resident had 75% to 100% meal intake. The ADON also reviewed Resident 12's Psychotropic Summary for Remeron's behavior manifestation of poor appetite from July 2020 to July 2021 did not clearly indicate the number of episodes of poor appetite. No GDR was done for Residents 8 and 12's Remeron use. During an interview on 8/6/21 at 9:37 a.m., the social services director (SSD) concurred that poor appetite for a specific resident should be accurate by indicating the meal percentage that would indicate poor appetite for a specific resident. It should be quantified and personalized. During an interview on 8/6/21 at 9:52 a.m., the pharmacy consultant (PC) reviewed Residents 8 and 12's clinical record and confirmed that GDR for their Remeron use were not attempted. The PC stated GDR should be done twice on the first year of use. The PC also concurred the monitoring for poor appetite should have been individualized and quantified to clearly identify the number of episodes. A review of the October 2017 policy and procedure, Psychotropic Medication Use, indicated the facility staff should take a holistic approach to behavior management that involves a thorough assessment of underlying causes of behaviors and individualized person--centered non-drug and pharmaceutical interventions. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms. Within the first year in which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 15 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 0758 Level of Harm - Minimal harm or potential for actual harm the resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility must attempt a GDR in two separate quarters unless clinically contraindicated. The facility staff should monitor behavior triggers, episodes, and symptoms and document the number and /or intensity of symptoms and the resident's response to staff interventions. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 16 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a medication error rate of 6.67% when two medication errors occurred out of 30 opportunities during medication administration for two out of ten residents (Residents 5 and 149). Residents Affected - Few The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which may result in residents not receiving the full therapeutic effect of the medications and could potentially compromise the residents' medical health. Findings: 1. During a medication pass observation on 8/3/21 at 08:20 a.m., licensed vocational nurse J (LVN J) administered Potassium (medication to prevent or to treat low blood levels of potassium) 20 milliequivalent (mEq. unit of measurement) one tablet to Resident 5 with less than half a glass (about 100 ml) of water. A review of Resident 5's minimum data set (MDS, an assessment tool) dated 5/28/21 indicated a brief interview of mental status (BIMS, an assessment tool for cognition) score of 15 or intact cognition. Her physician's order dated 5/28/21 included Potassium tablet 20 mEq by mouth one time a day for supplement, give with meals. During the record review and concurrent interview on 8/3/21 at 11:15 a.m., LVN J confirmed he administered Resident 5 her Potassium tablet at 8:22 a.m. and not with meals. LVN J stated he did not follow the doctor's orders. During an interview on 8/3/21 at 11:26 a.m., Resident 5 stated she ate her breakfast at 7:20 a.m. that morning and her usual breakfast time was between 7:00 a.m. to 7:20 a.m. During an interview on 8/3/21 at 11:26 a.m., certified nursing assistant M (CNA M) claimed he delivered Resident 5's breakfast tray at 7:10 a.m. 2. During a medication pass observation on 8/4/21 at 4:31 p.m., registered nurse E (RN E) administered Resident 149 the Sucralfate (medication to treat and prevent the return of duodenal ulcers)10 ml. (milliliter, unit of measurement) liquid suspension without shaking the bottle. During the concurrent interview, RN E validated the observation and stated she should have shaken the bottle to mix its contents. RN E concurred that the concentration of the medication would be different if shaken correctly and properly. During an interview on 8/5/21 at 12:34 p.m., the pharmacy consultant (PC) stated if the medication was ordered to be taken with meals then it should be given when a resident took his/her meals or few as close as possible about few minutes after meals to prevent or reduce side effects of the medications. The PC also stated the Sucralfate suspension should be shaken to have even dispersion of medications (for correct dosage). Review of the facility's October 2017 policy, Medication Administration-General Guidelines, indicated medications are to be administered as prescribed in accordance with good nursing principles and practices and in accordance with the written orders of the attending physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 17 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 0759 Level of Harm - Minimal harm or potential for actual harm Review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Sucralfate suspension, shake the oral suspension (liquid) before you measure a dose. Use the dosing syringe provided, or use a medicine dose-measuring device. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 18 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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** Based on observation, interview and record review, the facility failed to ensure medications and biologicals were stored, labeled and disposed appropriately when inspections of two of three medication carts found: 1. Medication Cart #1 a. Multiple opened insulin pens and insulin multidose vial not dated. b. Multiple controlled medications (those with high potential for abuse or addiction) of discharged or transferred residents and discontinued medications were kept at the locked compartment containing controlled medications were identified. c. Multiple liquid medications of either discharged /transferred residents were not dated and stored in the medication cart. d. Narcotic count sheet inconsistent with the amount remaining in the blister card (bubble packa pharmacy-prepared paperboard with medications in individual doses that can be punched out of the card when administered) seen during the medication reconciliation. 2. Medication Cart #2: a. One opened multidose insulin vial not dated. b. Two liquid medications opened and not dated. These failures could result in the accidental administration of discontinued, expired, or contaminated medications, or biologicals to residents. Findings: 1. During an inspection of Medication Cart #1 with registered nurse D (RN D) on [DATE] at 12:30 p.m., there were: a. Three insulin pens (Victoza pen, Basaglar insulin pen, Humulog mix 75-25 Kwikpen (medications to lower blood sugar) and one Lantus multidose insulin vial (long acting insulin to lower down blood sugar); b. Three bubble packs of Hydrocodone-APAP (pain medication), two bubble packs (51 tablets) Hydromorphone (pain medication) 2mg.(milligrams, unit of measurement), 20 tablets of MS Contin ER 200 mg. (pain medication), 41 tablets of Metronidazole (antifungal medication) 500 mg. , one tablet of Bactim (antibacterial), 20 tablets of Rifampicin (antibacterial), and 2 tablets of Amoxicalv (anti-infectives). c. Multiple opened bottles of liquid medications were not dated such as: Milk of Magnesia (for constipation), Gerilanta (antacid), Geritussin (for cough), Lactulose (laxative). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 19 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 d. Hydrocodone -APAP (pain medication) 5-325 mg. one tablet remaining in the bubble pack. The count sheet indicated there should be two remaining tablets. During the concurrent interview with RN D, she confirmed that those opened insulin medications mentioned above had no dates (Insulin injections or vials are good for 28 days once opened). RN D stated all discontinued controlled medications of discharged and/or hospitalized residents should be removed from the cart and should have been given to the director of nursing (DON) for safekeeping and accountability. RN D also stated she did not log the missing tablet in the Narcotic Count Sheet when she took two tablets but signed out one tablet of Hydrococodne- APAP which she administered to one resident on [DATE]. 2. During an inspection of Medication Cart #2 with registered nurse L (RN L) on [DATE] at 1:10 p.m., there was a multidose vial of Lantus insulin and two bottles of Geritussin which were opened and not dated. During an interview with the DON on [DATE] at 2:24 p.m., she stated nurses should immediately remove all discontinued controlled medications from the medication cart and give them to the DON for safekeeping and disposal prior to destruction with the pharmacist. Review of the facility's [DATE] policy and procedure, Disposal of Medications and Medication Related Supplies indicated, discontinued medications and medications left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit must be destroyed. Review of the facility's [DATE] policy and procedure, Controlled Medications, indicated when a controlled medication is administered, the licensed nurse administering the medication immediately enters in the accountability record the date and time of administration, amount administered and the signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 20 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure that the dietary aide (DA) knew how to check the dishwasher's temperature. This failure had the potential to affect 58 residents who received meals in the facility. A kitchen observation and interview were conducted with the dietary aide (DA), on 8/4/21, at 12:10 p.m., with the registered dietitian (RD) and the assistance of the cook to interpret. The DA, assigned in the dishwashing station, did not know how to check the temperature of the dishwasher. RD said the dishwasher was acquired in June, 2021. During an interview and record review with the RD on 8/5/21 at 3:30 p.m., RD said the DA has various kitchen duties, but mostly assigned to work in the dishwasher. Review of the facility's In-service, dated 6/28/21, titled Food and Nutrition Services, indicated the DA did not receive in-service on High Temp Dishmachine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 21 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 record review, the facility failed to ensure food was stored and prepared under sanitary conditions when: Residents Affected - Some 1. There were black patches on the wall behind the refrigerator, 2. Plastic containers in the storage shelf were still wet, 3. The red bucket (sanitizer bucket) and green bucket (soapy water or clean rinse water) were on top of the food preparation area, 4. There was a cup of coffee next to the coffee machine, without a lid on, and a purse on top of the food preparation table, next to the food spices. These failures had the potential to cause food contamination and illness to 58 residents who received their food from the kitchen. Findings: 1. During an initial kitchen observation on 8/2/21, at 8:30 a.m., with the registered dietitian (RD), at 8:40 a.m., there were black patches on the wall behind the refrigerator. During an interview with the maintenance assistant (MA) on 8/5/21, at 9:21 a.m, MA said the kitchen deep cleaning is done every 2 weeks, which includes cleaning the ceiling, walls, and back of the fridge. MA further stated the last deep cleaning was done on 7/30/21. He said there was no log or documentation for kitchen deep cleaning. 2. During a kitchen observation and interview with the RD on 8/2/21, at 9:04 a.m., noted were inverted plastic containers stacked together and still wet on a storage shelf. RD acknowledged the observation and said they should be dry. She further stated that the storage shelf was their drying and storage area. Review of the facility's policy, dated 2018, titled, 3 Compartment Procedure for Manual Dishwashing, indicated, All items are air-dried, which means no water droplets are present. 3. During a kitchen observation on 8/4/21, at 12:04 p.m, the red and green buckets were placed on top of the food preparation area, next to the container of brocolli. During an interview with the RD on 8/5/21, at 4:00 p.m., the RD confirmed the above observation and said that was where they usually place the buckets. Review of the Food Code 2017 website, indicated, Separation of poisonous and toxic materials in accordance with the requirements of this section ensures that food, equipment, utensils, linens, and single-service and single-use articles are properly protected from contamination. For example, the storage of these types of materials directly above or adjacent to food could result in contamination of the food from spillage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 22 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 Residents Affected - Some 4. During a kitchen observation and interview with the RD on 8/2/21, at 8:40 a.m., there was black coffee in a styrofoam cup next to the coffee machine, with no lid on it. RD said it was not supposed to be there. It might have been placed there from the tray cart. During a kitchen observation on 8/5/21, at 10:02 a.m., there was a purse on top of the food preparation table, next to the spices. RD immediately approached the kitchen staff (KS) to have her remove her purse from the table. During an interview with the RD on 8/5/21, at 10:15 a.m., RD acknowledged the above observation and said that KS removed her purse immediately and sanitized the table. However, the surveyors did not observe KS sanitize the table. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 23 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the skilled nursing facility did not coordinate hospice care for two of two sampled residents (Residents 26 and 150). Facility staff did not have a schedule for hospice nursing visits (RN, registered nurse and CNA, certified nursing assistant) and documented communication/coordination with hospice services. These failures resulted in the potential for lack of continuity of care for Residents 12 and 26 who were receiving hospice services at the facility. Findings: 1. A review of Resident 26's physician's order dated 3/19/21 indicated admit to hospice with diagnosis of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) without behavioral disturbance, and failure to thrive. During an interview and concurrent record review on 8/2/21 at 11:09 a.m., the medical records director (MRD) stated she completed Resident 26's chart audit last July 2021 and did not find any RN and CNA schedule of visits. MRD also stated the hospice agency did not send any RN and CNA schedule of visits even after she followed-up with the hospice agency. A review of the Hospice care plan dated 3/19/21 indicated staff will periodically visit the resident and anticipate needs. RN from hospice to visit as scheduled (see hospice schedule) and CNA from hospice to visit resident as scheduled (see hospice schedule). During a record review and concurrent interview on 8/04/21 at 2:25 p.m., the social services director reviewed Resident 26's clinical record and did not find any documented evidence on care coordination and collaboration between the facility and hospice staff soon after hospice admission on [DATE]. The SSD stated there should be care coordination and discussion of the plan of care (POC) after Resident 26's hospice admission so the family and facility were aware of the POC. 2. A review of Resident 150's clinical record indicated she was admitted to hospice care on 7/30/21 due to brain mass and encephalopathy (damage or disease that affects the brain, which occurs when there has been a change in the way the brain works). During a record review and concurrent interview on 8/5/21 at 8:37 a.m., the MRD, SSD and the assistant director of nursing (ADON) reviewed Resident 150's clinical record and did not find any documented evidence that a hospice staff schedule was sent to the facility after Resident was admitted to hospice. The coordination and collaboration of care regarding the resident's care after an elopement episode during the IDT (interdisciplinary, team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological and spiritual needs of the resident) meeting done on 8/2/21. During an interview on 8/8/21 at 9:05 a.m., the case manager (CM) stated there should be a hospice staff's schedule that would be provided to the facility ahead of time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 24 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility's revised July 2017 policy and procedure Hospice Program, indicated the facility designates a staff to coordinate care provided by the facility and the hospice staff and is responsible for collaborating with hospice representatives and coordinating facility staff participation in the hospice panning process for residents receiving these services, communicating with hospice representatives and other health care providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family. Event ID: Facility ID: 055800 If continuation sheet Page 25 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 Based on observation, interview and record review the facility failed to follow infection control measures when staff did not properly handle dirty linens and when the oxygen concentrator's filters were not changed for Residents 22 and 2. This failure had the potential to spread infection to self and others. Residents Affected - Few Findings: 1. During the initial rounds on 8/2/21 at 10:34 a.m., certified nursing assistant A (CNA A) removed Resident 12's bedding and carried it close to her body touching her uniform. During the concurrent interview CNA A validated the observation and stated she should carry dirty lines away from her body to prevent self-contamination. The assistant director of nursing (ADON) who was present stated CNA A should not carry dirty linens close to her body because this could contaminate her. A review of the facility's October 2018 policy and procedure, Soiled Laundry and Bedding, indicated soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. All used laundry is handled as potentially contaminated until it is properly bagged and labeled for appropriate processing. Contaminated laundry is placed in a bag or container at a location where it is used and not sorted or rinsed at the location of use. Contaminated laundry bags/containers are not held close to the body or squeezed during transport. 2a. During an observation on 8/2/21 at 9:51 a.m., in Resident 22's room, Resident 22 was lying in bed, using a nasal cannula (NC, a device that consists of plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostrils for oxygen administration). The oxygen concentrator's filter (black foam that catches dirt or dust) located at the back was filled with grayish particles. During an observation on 8/4/21 at 10:18 a.m., the oxygen concentrator's filter still had grey particles. During a concurrent observation and interview on 8/4/21 at 2:02 p.m., with Registered Nurse L (RN L), inside Resident 22's room, RN L confirmed that the filter was not changed. 2b. During an observation on 8/2/21 at 2:55 p.m., inside Resident 2's room, Resident 2 was on oxygen running continuously. The oxygen filter located at the side of the concentrator was filled with grayish particles. During an interview with the director of nursing (DON) on 8/5/21 at 8:52 a.m., she confirmed that the oxygen filters should be changed by maintenance on a regular basis. During an interview with the maintenance assistant (MA) on 8/5/21 at 9:21 a.m., he confirmed that he is responsible for checking the oxygen's filter weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 26 of 27 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 055800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Health and Rehabilitation 350 DE Soto Drive 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to maintain a functional and safe environment for 2 out of the 26 sampled residents (Residents 43 and 46) related to bedside tables with rough edges, peeled paint on wall, and a broken phone line. These failures had the potential to affect the safety and well-being of the residents in the facility. Findings: During an observation at Resident 43's room on 8/2/21, at 3:20 p.m., while the resident was lying in bed, paint was peeled off the wall behind resident's bed, the bedside table had rough edges, and her phone line was broken. During an observation on 8/2/21, at 3:53 p.m., in Resident 46's room, the resident's table had rough edges. During observation and concurrent interview with licensed vocational nurse J (LVN J) on 8/4/21, at 2:40 p.m., he confirmed the above observations. During an observation and concurrent interview with the maintenance assistant (MA) on 8/5/21, at 9:27 a m., MA acknowledged the surveyor's observation and he stated he was not aware. Review of the facility's policy, dated 12/2009, Maintenance Service, indicated, Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055800 If continuation sheet Page 27 of 27