Other·February 27, 2020

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 recertification survey conducted on 2/13/2020. The facility was licensed for 65 beds. The census at the time of the survey was 55. The sample size was 14. A Class "B" citation was also issued (see

F755). Representing the California Department of Public Health: 37409, Health Facilities Evaluator Nurse; 34383, Health Facilities Evaluator Nurse; and 42149, Health Facilities Evaluator Nurse.

F558 SS=D Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3)

F558 03/06/2020 §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure needs was accommodated for one of three sampled residents (Resident 21) when the call light device was not within reach. This failure had the potential for a delayed response and not meeting the resident needs. Findings: 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: ZMVY11 Facility ID: CA070000002 If continuation sheet 1 of 25 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 02/13/2020 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 21's clinical record indicated she had diagnoses of aphasia (loss of ability to understand or express speech), heart failure (a condition in which the heart can't pump enough blood to meet the body's needs), pain on the left and right foot. Review of Resident 21's minimum data set (MDS, an assessment tool) dated 12/13/19, indicated she had impaired cognition (memory problem), required assistance for bed mobility, dressing, eating, personal hygiene, and toileting. During an observation and interview with Resident 21 on 2/11/2020 at 10:43 a.m. and on 2/12/2020 at 8:24 a.m., she could not reach her call light device and the facility staff could not hear her when she called for help. During an interview with licensed vocational nurse F (LVN F) on 2/12/2020 at 8:23 a.m., she stated Resident 21's call light device was hanging below the side rail and she could not reach it. During an interview with the director of nursing (DON) on 2/12/2020 at 4:02 p.m., she stated Resident 21's call light device should have been within reach. Review of the facility's 7/2012 policy, "Call Light Answering", indicated the facility would provide the resident a means of communication with nursing staff. To place the call device within resident's reach before leaving the room.

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 03/06/2020 §483.21(b)(3) Comprehensive Care Plans FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 2 of 25 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 02/13/2020 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 The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on interview and record view, the facility failed to ensure licensed nurses were knowledgeable about the care for two of 14 sampled residents (32 and 55) when registered nurse D (RN D) did not know Residents 32 and 55 had pacemakers (an electronic device that is implanted in the body to monitor heart rate and rhythm; it gives the heart electrical stimulation when the heart does not beat normally), and registered nurse A (RN A) did not know Resident 55 had a pacemaker and did not know the signs and symptoms of a pacemaker malfunction. These failures had the potential to not identify the complications of the pacemaker which could lead to harm of the residents. Findings: Review of Resident 32's Admission Record indicated she was admitted to the facility on 6/14/18 with diagnosis of presence of cardiac pacemaker. Review of Resident 55's Admission Record indicated he was admitted to the facility on 1/28/2020 with diagnosis of presence of cardiac pacemaker. During an interview with RN A on 2/12/2020 at 1:45 p.m., she stated she did not know if Resident 55 had a pacemaker and she did not know the signs and symptoms of a pacemaker malfunction. During an interview with RN D on 2/12/2020 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 3 of 25 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 02/13/2020 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 4:15 p.m., she stated Residents 32 and 55 did not have pacemakers. The facility's 12/2015 policy, "Pacemaker, Care of a Resident with a", indicated "Monitor the resident for pacemaker failure by monitoring for signs and symptoms of bradyarrhythmias. Symptoms associated with bradyarrhythmias may include: syncope (fainting), shortness of breath, dizziness, fatigue, and/or confusion."

F698 SS=D Dialysis CFR(s): 483.25(l)

F698 03/09/2020 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide necessary care and services for one of two sampled residents (Resident 263) when: 1. The facility failed to administer medications when Resident 263 was scheduled for dialysis (a medical treatment using special machines to filter waste and excess water in the body) as ordered by the physician; 2. The facility failed to follow the fluid restriction as ordered by the physician; and 3. The facility failed to notify the physician related to significant weight gain and as ordered by the physician. These failures had the potential to compromise FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 4 of 25 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 02/13/2020 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 the health condition of the resident. Findings: 1. Review of Resident 263's clinical record indicated she had diagnoses including end stage renal disease (ESRD, a medical condition in which person's kidneys stop functioning), dependence on renal dialysis (the process of removing waste products and excess fluid from the body), muscle weakness, and diabetes (increase in blood sugar). Review of Resident 263's minimum data set (MDS, an assessment tool), dated 1/16/2020, indicated the resident had impaired cognition (memory problem). Review of Resident 263's physician order dated 1/10/2020, indicated to give Amylase (a medication contains digestive enzymes, which are natural substances needed by the body to help break down and digest food) 120,000 per 24 hours units three times daily with meals. Review of Resident 263's physician order dated 1/28/2020, indicated to give Phoslo (a calcium supplement used to control the level of phosphate in the blood for patients on dialysis due to severe kidney disease) capsule 667 milligrams (mg, unit of measurement) with meals. Review of Resident 263's medication administration record (MAR) for 1/2020, indicated Resident 263's Amylase was not administered on 1/17/2020, 1/19/2020, 1/24/2020, 1/29/2020, and 1/31/2020. Phoslo was not administered on 1/29/2020 and 1/31/2020. During an interview and record review with licensed vocational nurse G (LVN G) on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 5 of 25 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 02/13/2020 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 2/13/2020 at 8:46 a.m., she stated Resident 263 went to the dialysis at 5:30 a.m. and returned to the facility at 10:00 a.m. She stated she did not administer the phoslo and amylase medications for 7:30 a.m. due to Resident 263's scheduled dialysis. 2. Review of Resident 263's physician order dated 2/5/2020, indicated fluid restriction of 1.5 liters (L, a metric unit of volume) per day 24 hours. During an observation with Resident 263 on 2/10/2020 at 10:12 a.m., 2/11/2020 at 1:12 p.m., and 2/13/2020 at 8:46 a.m., Resident 263 observed drinking her personal bottled water and another bottled water on her bedside table. During an observation and interview with licensed vocational nurse F (LVN F) on 2/13/2020 at 9:00 a.m., she confirmed Resident 263 had a personal bottled water and one bottled water at the bedside table. LVN F stated Resident 263 should have no bottled water at bedside related to her fluid restriction. 3. Review of Resident 263's physician order dated 2/2/2020, indicated daily weights and notify the physician if weight variance of 2 pounds per day or 5 pounds per week every day. Review of Resident 263's MAR for 1/2020, indicated Resident 263's weight on 1/22/2020 was 134.6 pounds and on 1/23/2020 was 142.2 pounds. There was no indication the physician was notified regarding the weight variance of 2 pounds per day. During an interview and record review with the director of nursing (DON) on 2/13/2020 at 9:13 a.m., she confirmed the phoslo and lipase medications should have been administered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 6 of 25 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 02/13/2020 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 the physician should have been notified to clarify the order. The DON stated Resident 263 should have no bottled water at the bedside and the physician order for fluid restriction should have been followed. The DON also confirmed the physician was not notified related to the weight gain of 7.6 pounds per day on 1/23/2020. During an interview with the registered dietician (RD) on 2/13/2020 at 1:15 p.m., she stated Resident 263 had a significant weight gain and the nurses should have notified the physician. The RD also stated Resident 263 did not follow the fluid restriction and could cause significant weight gain. Review of the facility's 2016 policy, "Medication and Treatment Order", indicated orders for medications and treatment should have been administered upon written order of person duly licensed and authorized to prescribe such medications in this state. Review of the facility's 10/2010 policy,"Encouraging and Restricting Fluids", indicated the purpose of this procedure was to provide the resident with the amount of fluids necessary to maintain optimum health. Remove the fluid container to the resident's room.

F755 SS=F Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 02/17/2020 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 7 of 25 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 02/13/2020 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 general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure narcotic medications were disposed of in a safe manner when unlicensed personnel had access to narcotic medications. Findings: During an interview on 2/13/2020 at 12:42 p.m., the DON explained the narcotic disposal process at the facility. The DON stated the narcotics to be disposed of were given to her from the nurses. She stated she then locked them in a cabinet in her office. The DON stated, once a month, when the pharmacist was onsite at the facility, they wasted the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 8 of 25 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 02/13/2020 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 narcotics by collecting an unlocked bin in the locked medication storage room that contained wasted non-narcotic medications. The DON continued stating the pharmacist and her would then put the narcotics to be wasted in the bin and mix them with water. Next, the DON stated she would give the medications to the housekeeping supervisor to be incinerated. During a concurrent observation and interview on 2/13/2020 at 2:20 p.m., with the DON and the central supply (CS), at the storage cabinet outside and in the back of the facility, the CS unlocked the padlock to a tall plastic cabinet. Inside the cabinet were boxes of storage items to be picked up by the biohazard waste company. The CS stated the housekeeping supervisor and her were the only ones with the keys. The CS stated the biohazard waste company picked up the medications to be incinerated, but until then, they were kept in this cabinet. During an interview on 2/13/2020 at 2:31 p.m., the pharmacist stated the narcotics should not be stored in the cabinet outside. The pharmacist stated the wasted narcotics should stay locked up with the DON until the biohazard waste company came, as they needed to be doubled locked. The pharmacist stated the DON should not give the narcotics to housekeeping or central supply. During a review of the facility's policy and procedure (P&P), "Disposal of Medications and Medication-Related Supplies", dated January 2013, indicated "Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations ... The director of nursing and the consultant FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 9 of 25 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 02/13/2020 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 pharmacist are responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications ... Scheduled II-V controlled substances remaining in the facility after a resident has been discharged, or the order discontinued, are disposed of in the facility by the director of nursing or designated facility registered nurse in conjunction with the pharmacist."

F759 SS=D Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 03/03/2020 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility had a 12% medication error rate when three medication errors out of 25 opportunities were observed during medication passes for two out of five residents (Residents 8 and 40). 1. For Resident 8, the facility failed to ensure one medication, lidocaine hydrochloride (lidocaine HCl, a topical pain medication) was given as prescribed by the physician; and 2. For Resident 40, the facility failed to ensure two medications, calcium/vitamin D and lidocaine patch (a patch to apply to the skin for pain), were available and given as prescribed by the physician. These failures resulted in medications not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 10 of 25 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 02/13/2020 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 given as ordered by the physician and had the potential to compromise the residents' medical health. Findings: 1. During a review on 2/10 to 2/13/2020 of Resident 8's clinical record, indicated, Resident 8 had diagnoses that included peripheral vascular disease (gradual blockage of the blood vessels that supply the extremities), chronic heart failure (CHF, a chronic condition that results when the heart muscle is unable to pump blood efficiently), and polyneuropathy (a condition in which a person's peripheral nerves are damaged resulting in sensory disturbances in the limbs that causes numbness, tingling, burning and/or weakness). During a review of Resident 8's physician's orders entitled "Woodlands Healthcare Center Order Summary Report", dated 2/11/2020, indicated Resident 8 had an order for "Aspercreme Lidocaine Liquid 4% (lidocaine HCl). Apply to both lower legs topically two times a day for pain". The order had a start date of 12/14/2019. There was no end date. During a medication pass observation for Resident 8 on 2/11/2020 at 8:41 a.m., registered nurse A (RN A) looked through the medication cart for the topical lidocaine for Resident 8. RN A stated there was not any in the medication cart. RN A then proceeded to check the wound cart and stated there was none in there either. RN A stated she would call the pharmacy. After a few minutes, RN A returned to the medication cart and stated the director of nursing (DON) was going to change the order. During an observation on 2/11/2020 at 8:50 a.m., the DON brought a tube of "Arthritis FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 11 of 25 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 02/13/2020 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 Relief Cream 10% Trolamine Salicylate" (used for relief of minor aches such as in arthritis, simple back pain, strains, and joint & muscle pains) to RN A for Resident 8. RN A stated the DON updated the physician's orders and added the arthritis relief cream. During an interview on 2/12/2020 at 2:12 p.m., RN A stated there was lidocaine HCl 4% liquid in the medication cart for Resident 8 yesterday morning. RN A stated she did not know it was the correct medication. During an interview on 2/12/2020 at 3:47 p.m., the DON stated she checked with another nurse and the lidocaine HCl 4% was the correct medication but RN A did not know it. The DON stated, Trolamine Salicylate Cream 10% was started on 2/11/2020 after lidocaine HCl could not be located and the lidocaine HCl was then discontinued. 2. During a review on 2/10 to 2/13/2020 of Resident 40's clinical record, indicated, Resident 40 had diagnoses that included bilateral (both sides) primary osteoarthritis (a degenerative joint disease) of hips, muscle weakness, difficulty in walking, and cancer of prostrate and bone. During a review of Resident 40's physician's orders entitled "Woodlands Healthcare Center Order Summary Report", dated 2/11/2020, indicated Resident 40 had an order for "Calcium/Vitamin D tablet 500-200 milligrams (mg, a metric unit of mass)-unit ... Give one tablet by mouth two times a day for supplement", with a start date of 1/10/2020, and "Lidocaine Patch 5 %. Apply to bilateral flank (lower back/upper hips) topically one time a day for pain and remove per schedule". The lidocaine patch had a start date of 1/10/2020. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 12 of 25 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 02/13/2020 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 During a review of Resident 40's Medication Administration Record (MAR) for February 2020, indicated the lidocaine patch 5% was scheduled for topical application at 9:00 a.m. daily. During a medication pass observation for Resident 40, on 2/11/2020 at 8:15 a.m., registered nurse A (RN A) looked for the calcium 500 mg/vitamin D 200 unit supplement. RN A left the medication cart and then returned stating she was not going to give the calcium/vitamin D supplement to Resident 40 "right now" because the facility did not have the correct dosage. Further observation of the medication pass indicated there was no lidocaine patch available for Resident 40. RN A asked Resident 40 if he wanted his lidocaine patch and he stated he would take it later. During a subsequent observation, licensed vocational nurse C (LVN C) spoke with Resident 40 regarding his licocaine patch. Resident 40 stated he wanted his patch on after his shower and did not want to change the scheduled time. During an interview on 2/11/2020 at 3:12 p.m., the DON stated the lidocaine patch was not reordered and therefore the facility did not have it available. The DON stated the nurses should reorder when down to the last 3-4 days of supply. The DON confirmed this was not done. Additionally, the DON stated the calcium 500 mg/vitamin D 200 unit dosage was not a stock item. The DON stated initially central supply had ordered the correct dose. The DON stated since it was not a stock item she contacted the medical director who changed the dosage to match the stock dosage today. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 13 of 25 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 02/13/2020 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 During a review of the facility's policy and procedure (P&P), "Medication and Treatment Orders", with a revision date of July 2016, indicated "Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. " During a review of the facility's P&P under "Skilled Nursing Pharmacy", "Preparation and General Guidelines", dated April 2008, indicated "Medications are administered in accordance with written orders of the attending physician."

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 03/06/2020 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 14 of 25 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 02/13/2020 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 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure medication was stored under the correct temperature for one of four residents (41) when Resident 41's Latanoprost eye drops (used to treat high pressure inside the eye) that should be refrigerated were left at room temperature in the medication cart. This failure resulted in eye drops having a risk of being ineffective and/or unsafe. Findings: During an observation on 2/10/2020 at 4:15 p.m., of the medication cart at Station 2, indicated an unopened bottle of Latanoprost eye drops was in the medication cart for Resident 41. Further observation indicated the packaging stated "Refrigerate". During an interview on 2/11/2020 at 4:15 p.m., licensed vocational nurse B (LVN B) stated the eye drops should be refrigerated and proceeded to place the eye drops in the medication refrigerator. During an interview on 2/12/2020 at 4:14 p.m., the director of nursing (DON) stated the unopened Latanoprost eye drops should be refrigerated. During a subsequent interview on 2/13/2020 at 12:40 p.m., the DON stated the Latanoprost eye drops were thrown away. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 15 of 25 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 02/13/2020 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 the website at https://www.drugs.com/pro/latanoprostophthalmic-solution.html, indicated, "Store unopened bottle(s) under refrigeration at 2° to 8°C (36° to 46°F). During shipment to the patient, the bottle may be maintained at temperatures up to 40°C (104°F) for a period not exceeding 8 days. Once a bottle is opened for use, it may be stored at room temperature up to 25°C (77°F) for 6 weeks."

F806 SS=D Resident Allergies, Preferences, Substitutes CFR(s): 483.60(d)(4)(5)

F806 03/06/2020 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences; §483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to accommodate food preference for one of 14 sampled residents (3) when Resident 3 served food that he disliked to eat. This failure had the potential to affect his physical and psychosocial well-being. Findings: Review of Resident 3's clinical record indicated he had diagnoses including hypertension FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 16 of 25 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 02/13/2020 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 (increase in blood pressure), diabetes (increase blood sugar), and dementia (memory problem). Review of Resident 3's dietary slip undated, indicated Resident 3's dislike was spinach. During a dining observation with Resident 3 on 2/10/2020 at 12:22 p.m., Resident 3 was observed with nursing staff and he was not eating his food tray. Resident 3 had spinach on his food tray. During a concurrent interview with Resident 3, he stated he did not like spinach. During an interview with the director of staff development (DSD) on 2/10/2020 at 12:46 p.m., she confirmed Resident 3 had spinach on his tray and he should not have spinach on his food tray. During an interview with the dietary manager (DM) on 2/10/2020 at 12:57 p.m., she stated the menu had spinach and Resident 3 should not have spinach on his food tray. Review of the facility's undated policy, "Resident Food Preferences", indicated the individual food preferences would have been assessed upon admission and communicated to the interdisciplinary team (a group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best outcome for a patient or group of patients).

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 03/06/2020 §483.60(i) Food safety requirements. The facility must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 17 of 25 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 02/13/2020 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 §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food service when: 1. Undated opened box of orange juice in the dispenser; 2. Two undated opened bags of bread in the freezer; 3. Thirty pieces of unpasteurized eggs were used and served to the residents which was not fully cooked; 4. One big dented can of pinto beans and one big can of red raspberries dated 1/15/18; and 5. An opened grease trap while preparing and cooking foods. These failures had the potential to result in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 18 of 25 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 02/13/2020 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 cross contamination and could cause a food borne illness (illness caused by food or water contaminated with bacteria, viruses, parasite, or toxins). Findings: 1. During a kitchen observation and concurrent interview with dietary manger (DM) on 2/10/2020 at 7:53 a.m., an undated opened box of orange juice blend on the dispenser. The DM stated the orange juice should have been dated when they connected to the dispenser. Review of the facility's 2018 policy, "Dry Goods Storage Guidelines", indicated the storage length of fruit juices when opened and refrigerated was 5 days. 2. During an observation and concurrent interview with the DM on 2/10/2020 at 7:58 a.m., she stated two opened undated bags of bread in the freezer and the bread should have been dated. Review of the facility's 2018 policy, "Freezer Storage", indicated all frozen food should have been labeled and dated. 3. During a kitchen observation and interview with the DM on 2/10/2020 at 8:09 a.m., two big boxes of unpasteurized eggs. The DM stated she was not sure if the eggs were pasteurized. During an interview with the food delivery man (FDM) on 2/10/2020 at 8:11 a.m., he confirmed the eggs on the box were not pasteurized. During an interview with the kitchen cook (KC) on 2/10/2020 at 8:10 a.m., she confirmed she cooked sunny side up eggs (the eggs are cooked until the whites are set but the yolks are still runny) for residents' breakfast. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 19 of 25 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 02/13/2020 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 During an observation with Resident 257 on 2/10/2020 at 8:38 a.m., a sunny side up egg was on the plate and the resident was eating. During an interview with the registered dietician (RD) on 2/10/2020 at 3:38 p.m., she stated the unpasteurized eggs should have been fully cooked when they were served for the residents. Review of the facility's undated policy, "Eggs, Raw or Unpasteurized", indicated to cook until all parts of the eggs are completely firm to prevent food borne illness. 4. During a dry storage observation and concurrent interview with the DM on 2/10/2020 at 8:17 a.m., one big dented can of pinto beans and one big can of raspberries dated 1/15/18. The DM stated the dented can should have been separated and the one big can of raspberries was expired. Review of the facility's 2018 policy, "Food Storage - Dented Cans", indicated can with side seam, dents, rim dents or swell should have not retained or used by the facility. All dented cans and rusty cans are separated from remaining stock and placed in a specified labeled area. 5. During a kitchen observation on 2/10/2020 at 3:26 p.m., a maintenance man was inside the kitchen with a big hose and opened the grease trap inside the kitchen while the cook was preparing and cooking dinner. During an observation and interview with the RD on 2/10/2020 at 4:17 p.m., she stated the opened drainage hole was the grease trap and maintenance would clean it. The RD confirmed the grease trap was smelling inside the kitchen. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 20 of 25 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 02/13/2020 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 During an interview with the maintenance director (MD) on 2/12/2020 at 9:25 a.m., he stated the opened drainage hole was a grease trap and they came once a month to clean the drainage. The MD stated the maintenance man should have not cleaned the drainage when they prepared and cooked food for the residents. According to the FDA Food code 2017 as specified in paragraph 3-305.11 (A)(1) and (2) titled "Food Storage", indicated food shall be protected from contamination by storing the food in a clean, dry location where it was not exposed to dust or other contamination.

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 03/06/2020 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 21 of 25 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 02/13/2020 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 national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 22 of 25 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 02/13/2020 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 IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: 2. During an observation on 2/11/2020 at 8:40 a.m., of the medication cart at Station 1B, the red biohazard sharps container that was attached to the side of the medication cart and contained used needles, was over the maximum fill line. During an interview on 2/11/2020 at 8:40 a.m., registered nurse A (RN A) stated housekeeping staff were responsible for replacing the sharps container when full. During an interview on 2/11/2020 at 8:42 a.m., the director of nursing (DON) confirmed housekeeping was responsible for removing and replacing the sharps container when full. The DON also confirmed the sharps container was over full and should be replaced. Review of the facility's policy and procedure, "Sharps Disposal", with a revision date of January 2012, indicated "Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container. " 3. During a review of the clinical record, indicated Resident 8 had diagnoses that included unspecified macular degeneration (a vision impairment resulting from deterioration of the central part of retina). During a review of the physician's orders, indicated Resident 8 had medications that included: "Refresh Relieva Solution ...Instill 1 drop in both eyes two times a day ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 23 of 25 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 02/13/2020 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 During an observation on 2/11/2020 at 8:55 a.m., RN A administered "Refresh" eye drops to Resident 8. During the observation, RN A touched Resident 8's face with her bare fingers and for both eys, she pulled the lower eyelid down and raised the upper brow, as she administered eye drops. During an interview on 2/11/2020 at 9:10 a.m., RN A stated the facility's procedure for eye drop administration was to wear gloves only if the resident had an infection. During an interview on 2/11/2020 at 9:20 a.m., the director of staff development (DSD) stated gloves should be worn while administering eye drops. During a review of the facility's policy and procedure, "Instillation of Eye Drops", last revised January 2014, indicated "The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes...Steps in the Procedure...2. Wash and dry your hands thoroughly. 3. Put on gloves...7. Gently pull the lower eyelid down...Gently dry the eyelid with cotton ball if dripping occurs...13. Remove gloves and discard into designated container. Wash and dry your hands thoroughly ..." Based on observation, interview, and record review, the facility failed to implement infection control practice when 1. Restorative nursing assistant E (RNA E) picked up Resident 14 and 16's breads, cut the breads open, and spread butter on the breads with her bare hands and without washing her hands; 2. The sharps container of the medication cart was overfull; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 24 of 25 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 02/13/2020 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 3. Registered nurse A (RN A) administered eye drops to Resident 8 without wearing gloves. These failures had the potential to result in the transmission of infection to the residents and staff. Findings: 1. During a dining observation on 2/10/2020 at 12:23 p.m., RNA E brought the lunch tray to Resident 16, picked up the bread, cut the bread open, and spread butter on the bread with her bare hands and without washing her hands. During a dining observation on 2/10/2020 at 12:30 p.m., RNA E brought the lunch tray to Resident 14, picked up the bread, cut the bread open, and spread butter on the bread with her bare hands and without washing her hands. During an interview with RNA E on 2/10/2020 at 12:34 p.m., she stated she should wash her hands before handling Resident 14 and 16's breads. The facility's 10/2017 policy, "Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices", indicated "Employees must wash their hands: ... Before coming in contact with any food surfaces ... Contact between food and bare (ungloved) hands is prohibited." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZMVY11 Facility ID: CA070000002 If continuation sheet 25 of 25