Other·March 9, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of an entity reported incident conducted on 2/17 and 3/6/17 For Entity Reported Incident CA00522501 regarding Quality of Care/Treatment, a federal deficiency was identified (see F323) and a Class "B" Citation was also identified. Inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 36043, Health Facilities Evaluator Nurse.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 03/19/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CXQ11 Facility ID: CA070000002 If continuation sheet 1 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055517 (X3) DATE SURVEY COMPLETED 03/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WOODLANDS HEALTHCARE CENTER 14966 Terreno De Flores Ln Los Gatos, CA 95032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to prevent an elopement (to leave a long term care facility without permission) and accident for one of two sampled residents (1) when Resident 1 was assessed as high risk for elopement, the facility did not intervene to reduce the risk of elopement. This failure resulted in Resident 1's elopement, falling backwards, and sustaining a six centimeter (cm, unit of measurement) hematoma (collection of blood outside the blood vessels, caused by trauma or injury) to the back of her head when she hit her head on the ground. Findings: Resident 1's clinical record was reviewed. The resident was admitted to the facility on 2/5/17 with a diagnosis of dementia (brain disease causing a long-term and often gradual decrease in the ability to think, remember, and affecting a person's daily functioning) and history of falls. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 2/12/17, indicated her cognition was severely impaired. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CXQ11 Facility ID: CA070000002 If continuation sheet 2 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055517 (X3) DATE SURVEY COMPLETED 03/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WOODLANDS HEALTHCARE CENTER 14966 Terreno De Flores Ln Los Gatos, CA 95032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 1's Physical Therapy Assessment dated 2/6/17, indicated the resident could walk on an even surface using a walker with minimum assistance. Review of Resident 1's Elopement Screening (ES) dated 2/5/17, indicated the total score for ES was "9" which meant the resident was at risk for elopement (the total score of "9" or above represents at risk for elopement). During review of Resident 1's clinical notes on 2/17/17, there was no documented evidence the elopement risk was addressed. During an interview with certified nursing assistant A (CNA A), on 2/17/17, at 12:25 p.m., she stated on 2/13/17 she took Resident 1 to the resident's room and sat the resident in the wheelchair. CNA A stated she could not remember if she attached the tab alarm to the resident. (Tab alarm clips to the back of the resident's clothing, and if the resident moves too far, the pull cord releases the magnet, and the alarm sounds to alert the caregiver the resident attempted to ambulate. This is used for fall management and wandering prevention.) Review of Resident 1's Nurses Notes dated 2/13/17, indicated at 5:45 p.m., the resident was missing and the staff performed a facility search but could not locate the resident. Review of Resident 1's Progress Notes dated 2/14/17 at 12:11 p.m. indicated the facility called the nearest acute hospital at 6:45 p.m. on 2/13/17 to inquire about their missing resident. The acute hospital informed them Resident 1 was brought by the paramedics to their hospital emergency room. She was crossing the street, was witnessed falling FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CXQ11 Facility ID: CA070000002 If continuation sheet 3 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055517 (X3) DATE SURVEY COMPLETED 03/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WOODLANDS HEALTHCARE CENTER 14966 Terreno De Flores Ln Los Gatos, CA 95032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE backwards, and hitting her head. Review of Resident 1's History and Physical from the acute care hospital dated 2/13/17, indicated the resident was crossing the street and was witnessed falling backwards hitting her head on the ground. The resident sustained a six cm hematoma to the back of her head. During an interview with the minimum data set coordinator (MDS C), on 2/17/17, at 1:00 p.m., she acknowledged Resident 1 was assessed during admission as high risk for elopement. She stated the facility did not initiate elopement risk interventions (i.e., WanderGuard) because the resident had a hip fracture and she never thought the resident could walk. During an interview with the director of nursing (DON), on 2/17/17, at 2:30 p.m., she stated she did not initiate the elopement risk interventions (i.e., WanderGuard) because Resident 1 was not ambulatory due to a hip fracture. During an interview with physical therapist B (PT B), on 2/24/17, at 10:30 a.m., she stated during the assessment on 2/6/17 using a walker, Resident 1 could walk 100 feet with minimum assistance. Review of the facility's policy "Elopement Risk Assessment" dated 03/2010, indicated the facility was to provide a safe environment for all the residents. Residents who are at risk for elopement will have an appropriate plan of care developed to address the risk. Review of the facility's policy "Wander Monitoring System" dated 03/2010, indicated residents identified to be at risk for elopement will have a wander monitoring bracelet to reduce the risk for elopement. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CXQ11 Facility ID: CA070000002 If continuation sheet 4 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055517 (X3) DATE SURVEY COMPLETED 03/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WOODLANDS HEALTHCARE CENTER 14966 Terreno De Flores Ln Los Gatos, CA 95032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: 3CXQ11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA070000002 (X5) COMPLETE DATE If continuation sheet 5 of 5