Health inspection·June 4, 2025

F 0610 Respond appropriately to all alleged violations. 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 complete and submit an investigation summary regarding an alleged abuse incident that occurred between two of three sampled residents (Residents 1 and 2). Residents Affected - Few This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incident and could have compromised the residents' safety. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had the diagnosis of cellulitis (a skin infection that causes swelling and redness) of left and right limb, peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs), abnormal posture and history of falling. Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 3/18/25, indicated she had a (Brief Interview for Mental Status, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) BIMS of 12 meaning her cognition was moderately impaired. Review of Resident 2's medical record indicated she was admitted on [DATE] and had the diagnosis of alcohol dependence with withdrawal, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), abnormal posture and history of falling. Resident 2's MDS dated [DATE], indicated she had a BIMS of 7 meaning her cognition was severely impaired. Review of Resident 1's Change in Condition Evaluation, dated 4/1/25, indicated an incident had occurred between Resident 1 and Resident 2. The documentation indicated, nurse heard yelling and argument with roommate Resident 2. During a concurrent interview and record review on 6/4/25 at 9:40 a.m., with the Director of Nursing (DON), she reviewed interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) IDT note dated 4/5/25 and stated that on 4/1/25 around 11:50 p.m., staff heard Resident 1 and Resident 2 yelling to each other and charge nurse transferred Resident 2 to another room. In the morning of 4/2/25, Resident 1 told the DON and the Social Services Director (SSD) that her roommate Resident 2 tapped her on the back of the head, and she was not comfortable. The DON and charge nurse assessed Resident 1 and no visual injury noted and denies pain or discomfort and the primary doctor (MD) was notified. (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: 055800 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 06/04/2025 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)