Other·April 19, 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 recertification survey conducted from 4/3/17 through 4/6/17. A Class "B" Citation was also issued under

F226. The facility was licensed for 148 beds. The census at the time of the survey was 140. The sample size was 24. Representing the California Department of Public Health: 36045, Health Facilities Evaluator Nurse; 32999, Health Facilities Evaluator Supervisor; 33651, Health Facilities Evaluator Supervisor; 10918, Health Facilities Evaluator Nurse; 32892, Health Facilities Evaluator Nurse; 35157, Health Facilities Evaluator Nurse; and 35302, Health Facilities Evaluator Nurse.

F166 SS=D RIGHT TO PROMPT EFFORTS TO RESOLVE F166 GRIEVANCES CFR(s): 483.10(j)(2)-(4) 05/04/2017 (j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. (j)(3) The facility must make information on how to file a grievance or complaint available to the resident. (j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents’ rights 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: MWR711 Facility ID: CA070000003 If continuation sheet 1 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: (i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; (ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; (iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; (iv) Consistent with §483.12(c)(1), immediately FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 2 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law; (v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident’s grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident’s concerns (s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued; (vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents’ rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents’ rights within its area of responsibility; and (vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to ensure residents' complaints about a noisy resident (10) were responded to. During resident group and individual meetings, residents expressed displeasure about staff not resolving the problem of Resident 10's behavior of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 3 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 continued yelling and banging on the wall. This failure caused distress to the residents. Findings: During a group meeting on 4/3/17 at 2 p.m., several residents voiced a grievance of a resident yelling and banging an object against a wall of his bedroom and disturbing their peace. Residents stated staff were aware of the problem but the yelling and banging continued. Resident 31, during the same interview, stated it was noisy everyday for "24 hours." During an interview on 4/4/17 at 8:30 a.m., Resident 6 stated a resident across the hallway was banging and making loud noises. Resident 10 yelled, cursed and banged an object on the wall day and night and Resident 6 could not sleep at night. During an interview on 4/4/17 at 2:40 p.m., licensed vocational nurse (LVN) H stated Resident 10 had behaviors of yelling, being demanding and banging the wall with a back scratcher, usually during shift change. Two residents (6 and 31) complained about the noise about a week prior. LVN H would not take away Resident 10's backscratcher or he would yell. During an interview on 4/4/17 at 3:30 p.m., certified nurse assistant (CNA) P stated Resident 10 had been yelling, cursing and screaming every day after 8 p.m. to staff and other residents. CNA P stated Resident 10 used a stick to hit a wall, yelled for five minute after care, and sometimes called the front desk and complained. Other residents (6 and 31) complained also about Resident 10. CNA P stated he reported to the charge nurse about Resident 10. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 4 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 on 4/4/17 at 3:45 p.m., Resident 2 stated a resident in a room next to her was very loud, and he banged on the wall. Resident 2 stated when she once went to his room the resident "told me to go to h---." During an observation in Resident 2's room on 4/4/17 at 3:45 p.m. at the time of the above interview, Resident 10 was heard yelling and banging on the wall with an object for several minutes. A review of Resident 10's record indicated he was admitted to the facility on 3/19/13. The Minimum Data Set (MDS, an assessment tool) dated 1/16/17 indicated Resident 10 did not have problems with memory and daily decisionmaking skills. He had a care plan dated 9/11/16, addressing verbal aggression of "abusive" behavioral symptoms of threatening, screaming, and cursing at staff and roommates. During an observation on 4/5/17 at 8:55 a.m., Resident 10 had a wooden back scratcher on his bed. The bed was next to the wall on Resident 10's right side. During an interview at the time of observation on 4/5/17 at 8:55 a.m., Resident 10 acknowledged he yelled and banged the wall with his back scratcher because staff were busy and they could not come to assist him when one staff had 12 to 14 residents to take care of. Resident 10 added, "When I need something I want to get it right away", and described himself as "spoiled." A review of the facility's grievance binder indicated there was no grievance filed. During an interview on 4/4/17 at 9:50 a.m., the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 5 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 social services assistant (SSA) stated the social services department handled grievances. The SSA stated two residents approached her complaining they could not sleep because of Resident 10's noisy behavior. The SSA stated she did not file the residents' complaints as grievances because they did not request it as such. During a follow-up interview on 4/4/17 at 12:30 p.m., SSA O recalled Resident 10 had been yelling for about a year and he was audible to the end of the hallway. When Resident 10 yelled, the SSA stated, he often asked for pain medication and he would curse and call people names. She said he was currently yelling approximately six times per day. During an interview on 4/6/17 at 8:15 a.m., the director of social services stated she was aware of Resident 10's behavior of yelling and being loud. She stated complaints were not taken as grievances unless the residents had them filed as grievances. The undated policy "Resident Grievance/Complaint Procedures" indicated a resident may file a verbal or written grievance or complaint. It was the policy of the facility to assist in filing a grievance or complaint.

F176 SS=D RESIDENT SELF-ADMINISTER DRUGS IF DEEMED SAFE CFR(s): 483.10(c)(7)

F176 05/04/2017 (c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 6 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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, the facility failed to perform an interdisciplinary team ((IDT), staff from different departments who coordinate the residents' care) re-assessment, store bedside medication in a secure place, and obtain a physician order for one of 24 sampled residents (Resident 12) when a bottle of liniment oil (an over-thecounter mentholated oil formulated to provide instant relief for pain) was found in Resident 12's room. This failure had the potential to allow for unsafe and improper administration of medication. Findings: During a meal observation on 4/4/17, at 12:45 p.m., in Resident 12's room, one bottle of liniment oil was found on top of her bedside table. During a concurrent interview with Resident 12, she stated the liniment oil had always been available at her bedside because she personally applied the oil whenever she had pain to her knees. During a review of the Resident 12's clinical record the Minimum Data Set ((MDS), an assessment tool) dated 1/2017 indicated moderate impairment with her cognitive status. The physician's order did not show an order for liniment oil. The last IDT assessment for selfadministration was on 9/17/14. During an observation with assistant director of nursing K (ADON K) on 4/4/17, at 2:50 p.m., in Resident 12's room, one bottle of liniment oil was seen on top of the resident's bedside table next to a bottle of lotion. The ADON requested Resident 12 place the bottle inside her secured drawer. During an interview and record review with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 7 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 ADON K on the same date, at 3:15 p.m., she acknowledged the bedside medication should be stored in a locked drawer. She also confirmed the physician's order dated 2/2015 indicated liniment oil was discontinued on 2/17/15. There was no record the medication order was renewed. The ADON K stated no IDT re-assessment for self-medication was done after 9/2014. Review of the facility's 8/2006 policy and procedure titled "Self-administration of Drugs", indicated self-administered medications must be stored in a safe and secure place. The staff and practitioner will periodically reevaluate a resident's ability to continue to self-administer medications.

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 05/01/2017 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff onFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 8 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 (c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report to the California Department of Public Health (CDPH), or the Ombudsman, or the police, when Resident 1 reported to facility staff regarding an incident of Resident 15 grabbing Resident 1's hand and not letting go on 4/2/17. The failure to report the alleged abuse prevented an analysis of the occurrence to determine any changes necessary to prevent future abuse, and potentially allowed the abuse to continue. Findings: During an interview with Resident 1, on 4/4/17, at 12 p.m., she stated her roommate, Resident 15, was "crazy and not rational". Resident 1 stated Resident 15 "suddenly" grabbed her hand and did not let her hand go when she passed by Resident 15 on 4/2/17. Resident 1 stated she felt "irritated and a little scared" when Resident 15 grabbed her hand. Resident 1 stated her hand was hurt when Resident 15 grabbed it. Resident 1 stated she reported the incident to facility staff right away. A review of Resident 1's minimum date set (MDS, an assessment tool) dated 2/8/17 indicated Resident 1 had no cognitive impairment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 9 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 Resident 15, on 4/4/17, at 1:22 p.m., she stated Resident 1 grabbed her cubicle curtain without her permission. Resident 15 stated she was "angry" and grabbed Resident 1's hand and pulled Resident 1's wrist away last Sunday. A review of Resident 15's MDS dated 3/8/17 indicated Resident 15 had no cognitive impairment. Resident 15's clinical record indicated she had a diagnoses of psychotic disorder with delusion (false belief or opinion against the fact) due to known physiological condition. During an interview with licensed vocational nurse X (LVN X), on 4/4/17, at 4:26 p.m., he stated Resident 1 reported to him that Resident 15 grabbed Resident 1's hand when Resident 1 passed by Resident 15 around six to seven o'clock on 4/2/17 . LVN X stated Resident 1 was alert, forgetful at times and able to tell staff what she needed. LVN X stated he reported the incident to the director of nursing (DON) right away on 4/2/17. During an interview with the administrator (ADM), the facility abuse coordinator, on 4/4/17, at 9:45 a.m., he stated the evening nurse reported the incident to the DON, and the DON reported the incident to the ADM on 4/2/17. The ADM stated the facility did not reported this alleged resident to resident incident to CDPH, or the Ombudsman, or the police. The ADM stated the facility did not consider this incident as resident to resident abuse after facility staff interviewed both residents and staff. During an interview with the ADM, on 4/4/17, at 12:35 p.m., he stated social service "just" followed up with Resident 1 approximately 20 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 10 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 minutes ago. Per social service, Resident 1 stated Resident 15 grabbed her hand on 4/2/17 and did not let her hand go. The ADM stated that based on social service's new information from Resident 1's interview, the facility should have reported this incident to CDPH, the Ombudsman and the police department. A review of the facility's revised policy dated March 2013, " Reporting abuse to Facility Management", indicated when an alleged or suspect abuse is reported, the facility administrator or his designee should "immediately" (within 24 hours of the alleged incident) report to CDPH, Ombudsman and Law Enforcement Officials.

F279 SS=D DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d);483.21(b)(1)

F279 05/04/2017 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c) (3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 11 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (iv)In consultation with the resident and the resident’s representative (s)(A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to develop can plans for two of 24 sample residents (1 and 15) when Resident 1 reported to staff that Resident 15 grabbed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 12 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 Resident 1's hand and did not let her hand go on 4/2/17. The facility also failed to revise the care plan of at risk for decline in functional mobility for one of 24 sampled residents (7). These failures had potential to result in further resident to resident physical aggression (such as hitting, kicking, grabbing, and etc.) between Residents 1 and 15, and decline of Resident 7's physical condition. Findings: 1. During an interview with Resident 1 on 4/4/17 at 12 p.m., she stated her roommate, Resident 15, was "crazy and not rational". Resident 1 stated Resident 15 "suddenly" grabbed her hand and did not let her hand go when she passed by Resident 15 on 4/2/17. Resident 1 stated she felt "irritated and a little scared" when Resident 15 grabbed her hand. Resident 1 stated her hand was hurt when Resident 15 grabbed it. Resident 1 stated she reported the incident to the facility staff right away. A review of Resident 1's minimum date set (MDS, an assessment tool) dated 2/8/17 indicated Resident 1 had no cognitive impairment. During an interview with Resident 15 on 4/4/17 at 1:22 p.m., she stated Resident 1 grabbed her cubicle curtain without her permission. Resident 15 stated she was "angry" and grabbed Resident 1's hand and pulled Resident 1's wrist away the previous Sunday. A review of Resident 15's MDS dated 3/8/17 indicated Resident 15 had no cognitive impairment. During an interview with director of nursing (DON), on 4/4/17, at 2:26 p.m., the DON stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 13 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 evening nurse reported to him about Resident 15 allegedly grabbing Resident 1's hand. The DON stated there were no care plans for either resident for the incident. DON stated nursing staff and interdisciplinary team ((IDT), different department heads meet together to decide the care for the residents) should initiate care plans for both residents. A review of the facility's revised policy dated October 2009, "Care Plans-Comprehensive", indicated each resident's care plan is designed to "...Incorporate risk factors associated with identified problems." 2. Resident 7's clinical record was reviewed and indicated she was admitted with cerebral atherosclerosis (thickening and hardening of the walls of the arteries in the brain), glaucoma (increased eye pressure) and she was receiving hospice care. Her minimum data set ((MDS), an assessment tool) dated 3/1/17 indicated she had cognitive impairment and was dependent on staff for transfer and ambulation. An at risk for decline in functional mobility care plan was developed on 9/6/13 and was reviewed/revised on 3/4/17. The care plan indicated to place Resident 7 on the restorative nursing assistant (RNA) program for ambulation with a front wheel walker five (5) times a week. During multiple observations from 4/3/17 to 4/4/17, Resident 7 was not seen ambulating with RNA's. During an interview with RNA Q on 4/4/17 at 8:20 a.m., he stated Resident 7 was not on an RNA program. During an interview with licensed vocational nurse (LVN) R on 4/5/17 at 1:50 pm., she stated Resident 7's care plan should have been revised and updated as the RNA program was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 14 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 discontinued on 4/22/15. During an interview with LVN S on 4/5/17 at 3:15 p.m., she stated she updated and revised care plans quarterly. LVN S also stated Resident 7's care plan should have been revised to reflect her current status. A review of the facility's 12/ 2008 "Care Planning-Interdisciplinary Team" policy indicated care planning included development and revisions to the resident's care plan.

F280 SS=D RIGHT TO PARTICIPATE PLANNING CAREREVISE CP CFR(s): 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2)

F280 05/04/2017 483.10 (c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: (i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the personcentered plan of care. (ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. (iv) The right to receive the services and/or items included in the plan of care. (v) The right to see the care plan, including the right to sign after significant changes to the plan of care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 15 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 (c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-(i) Facilitate the inclusion of the resident and/or resident representative. (ii) Include an assessment of the resident’s strengths and needs. (iii) Incorporate the resident’s personal and cultural preferences in developing goals of care. 483.21 (b) Comprehensive Care Plans (2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 16 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to conduct the interdisciplinary team (IDT, team members from different departments involved in a resident's care) care conference for one of 24 sampled residents (17). For Resident 17, the facility failed to conduct two quarterly IDT care conferences as scheduled, and conducted another two IDT care conferences with only one discipline in attendance. These failures had the potential to delay care planning to identify the specific care and services necessary to meet the residents' needs. Findings: A review of Resident 17's clinical record indicated her diagnosis included dysphasia (partial or complete loss of the ability to communicate) due to intracerebral hemorrhage (bleeding in the brain). Her 1/4/17 Minimum Data Set (MDS, an assessment tool) indicated her cognition was severely impaired. The clinical record review also indicated there was no quarterly IDT care conferences done on or around 04/2016 and 10/2016. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 17 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 A Review of Resident 17's IDT care conference note for 07/2016, recorded on 8/30/16, indicated only the resident and social services assistant O (SSA O) were in attendance. A review of the IDT care conference notes for 01/2017, recorded on 2/23/17, indicated only the responsible party and SSA O were in attendance. During an interview with social services assistant O (SSA O) on 4/6/17 at 10:25 a.m., she stated no IDT care conferences were done for 04/2016 and 10/2016 and there should have been. She also stated other disciplines such as nursing services, activity services, dietary services should have attended the IDT care conferences conducted on 07/2016 and 01/2016 and not just social services. During an interview with the administrator (ADM) on 4/6/17 at 11:10 a.m., he stated the IDT usually followed the quarterly assessment of the resident, and different disciplines attended, such as social services, nursing services, dietary as needed, and activities as needed. A review of the facility's 2001 policy revised on 09/2010, "Resident Assessment Instrument," indicated the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule at least quarterly and once every 12 months. Review of the facility's 2001 policy revised on 12/2008, "Care Planning - Interdisciplinary Team," indicated a Care Planning/Interdisciplinary Team included but is not necessarily limited to, the following personnel: the resident's Attending Physician, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 18 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 nursing services, dietary services, activity services, therapists, consultants and others as appropriate or necessary to meet the needs of the resident.

F282 SS=D SERVICES BY QUALIFIED PERSONS/PER CARE PLAN CFR(s): 483.21(b)(3)(ii)

F282 05/04/2017 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(ii) Be provided by qualified persons in accordance with each resident's written plan of care. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure proper implementation of care plans for two of 24 sampled residents (7 and 9). For Resident 7, a care plan for potential for skin breakdown was not implemented and for Resident 9, a care plan was not implemented. These failures could result in ineffective care planning and put residents at risk. Findings: 1. Resident 7's clinical record was reviewed and indicated she was admitted with cerebral atherosclerosis (thickening and hardening of the walls of the arteries in the brain), glaucoma (increased eye pressure) and she was receiving hospice care. Her minimum data set (MDS, an assessment tool) dated 3/1/17 indicated she had cognitive impairment and was dependent on staff for transfer and ambulation. A care plan for potential for skin breakdown, dated 3/4/17, indicated to place FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 19 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 Resident 7 on a pressure relief mattress. During an observation on 4/4/17 at 2:30 p.m., Resident 7 was lying on her bed. During an interview with registered nurse H (RN H) on 4/4/17 at 2:55 p.m., she confirmed that Resident 7 had a regular mattress. RN H stated Resident 7 should have been on a pressure relief mattress as care planned. A review of the facility's 3/2005 "Prevention of Pressure Ulcers" policy indicated the facility is responsible in identification of risk factors for pressure ulcer development and interventions for specific risk factors. 2. Resident 9's clinical record was reviewed and indicated she was admitted with diabetes mellitus, hypertension, and dementia. Her minimum data set (MDS-an assessment tool) dated 2/8/17 indicated she had cognitive impairment and was dependent for transfer and ambulation. A fall care plan, dated 6/20/16 indicated staff were to keep the bed in the lowest position with the brakes locked. During an observation on 4/4/17 at 2:45 p.m., Resident 9 was lying on bed. The bed was raised to hip level position. The facility staff were inside the room. During another observation on the same day at 3:15 p.m., Resident 9's bed was still raised to hip level position. During a concurrent interview with certified nursing assistant T (CNA T), he confirmed Resident 9's bed was raised to hip level position. CNA T stated Resident 9's bed should be kept in the lowest position as care planned. Review of the facility's 12/2007 " Falls and Fall Risk, Managing" policy indicated "based on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 20 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 previous evaluations and current data, the staff will identify interventions related to resident's specific risks and cause to try to prevent the resident from falling and to try to minimize complications from falling. The IDT will identify appropriate interventions to reduce the risk of falls and implement relevant interventions."

F309 SS=D PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 05/04/2017 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 21 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 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 ensure proper coordination of hospice care (a type of care and philosophy of care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain and symptoms, and attending to their emotional and spiritual needs) for one of 24 sampled residents (7). This failure could result to inadequate and ineffective provision of hospice care. Findings: Resident 7's clinical record was reviewed and indicated she was admitted with cerebral atherosclerosis (thickening and hardening of the walls of the arteries in the brain), glaucoma (increased eye pressure) and she was receiving hospice care. Her minimum data set (MDS, an assessment tool) dated 3/1/17 indicated she had cognitive impairment and was dependent on staff for hygiene and bathing. During an observation on 4/3/17 at 11:10 a.m., Resident 7 was sitting on her bed wearing a light blue dress. During an observation on 4/4/17 at 2:30 p.m., Resident 7 was wearing light blue dress and her hair was tangled. A review of the 4/4/17 Daily AssignmentMorning shift form indicated Resident 7 was scheduled for a shower and was assigned to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 22 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 certified nursing assistant G (CNA G). During an interview with CNA G on 4/4/17 at 3:05 p.m., he stated Resident 7's shower schedule was every Tuesday and Friday. CNA G stated the hospice aide should have given Resident 7 a shower. CNA G stated the hospice aide should inform and communicate with facility staff every visit. On 4/5/17 at 8:55 a.m., CNA G confirmed he did not complete Resident 7's skin sheet as the hospice aide did not communicate with him on 4/4/17. Review of Resident 7's Hospice Visit Schedule for the week of 4/2-4/8, posted on the bulletin board, indicated she was scheduled to be seen by a hospice nurse on Tuesday (4/4) and Thursday (4/6). During an interview with registered nurse H (RN H) on 4/4/17 at 2:55 p.m., she stated no hospice nurse spoke to her about Resident 7's care during her entire shift. During an interview and record review with RN H on 4/5/17 at 10:20 a.m., she confirmed there was no hospice visit documentation on 4/4/17 for Resident 7. During an interview with the director of nursing (DON) on 4/5/17 at 2:45 p.m., he stated effective communication between the hospice agency and facility staff is key in rendering quality resident care. The DON stated he was unsure if hospice staff visited Resident 7 on 4/4/17. A review of the facility's 4/2009 "Hospice Program" policy indicated "A coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 23 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status."

F328 SS=E TREATMENT/CARE FOR SPECIAL NEEDS CFR(s): 483.25(b)(2)(f)(g)(5)(h)(i)(j)

F328 05/04/2017 (b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident’s medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments (f) Colostomy, ureterostomy, or ileostomy care. The facility must ensure that residents who require colostomy, ureterostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences. (g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to … prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. (h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive personcentered care plan, and the resident’s goals FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 24 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 preferences. (i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents’ goals and preferences, and 483.65 of this subpart. (j) Prostheses. The facility must ensure that a resident who has a prosthesis is provided care and assistance, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents’ goals and preferences, to wear and be able to use the prosthetic device. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide the necessary care and treatment for two of 24 sampled residents (18 and 21) and 3 nonsampled residents (28, 29, and 30). For Resident 18, podiatry (specialized medical care and treatment of the human foot) care was not provided when the resident had long, curved toenails and her most recent podiatry care was eight months prior. For Residents 21, 28, 29, and 30, staff did not have baseline measurement of their external length and arm circumference when they had peripherally inserted central catheters (PICC, a long, slender, flexible tube inserted into a peripheral vein and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain intravenous access), or did not verify the difference of measurement. These failures resulted in Resident 18 having unkempt feet, and had the potential to result in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 25 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 inaccurate PICC placement causing possible complications for Residents 21, 28, 29, and 30. Findings: 1. A review of Resident 18's clinical record on 4/4/17 indicated she had a physician's order for a podiatry consult as needed. Resident 18's most recent podiatry visit was 7/20/16. During an observation and interview on 4/4/17 at 3:30 p.m., Resident 18 was in her bed and her feet were exposed. Her toenails, especially the great toenails, were long and curving over the end of the toe. During an interview at the time of observation, licensed vocational nurse (LVN) I described Resident 18's left and right great toenails as long and curved, and 3 cm (centimeter, a metric unit of measurement, one inch is 2.5 cm) in length (area situated farthest from the point of attachment). The left third and forth toenails were three cm and the second toenail was 2.5 cm in length. LVN I stated Resident 18 should have podiatry services. During an interview on 4/6/17 at 8:15 a.m., the director of social services (DSS) stated a podiatrist came to the facility every other week. A podiatry referral for Resident 18 was sent in February 2017 and the DSS did not know why there had been a delay in obtaining podiatry services. A review of Resident 18's podiatry note indicated her ten toenails were long and thickened and all nails were debrided (trimmed). The "Availability of Services, Podiatry" policy dated August 2013, indicated podiatry services was to be provided to residents as needed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 26 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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. Review of Resident 21's clinical record indicated the resident was admitted to the facility on 2/16/17 with a PICC inserted. There was no information available related to the PICC, including the external length upon admission. A review of Resident 21's treatment administration record (TAR) indicated on 2/23/17 the external length of the PICC was 3 centimeters (cm, unit of length) and on 3/8/17, it was "11" without a unit of measure. On 3/27/17 the external length was measured at 16 cm. There was no documented evidence the discrepancies were verified or reported to the physician. A review of Resident 28's clinical record indicated the resident was admitted to the facility on 3/21/17 with a PICC which was inserted in his right upper arm. His PICC Insertion Record from an acute care hospital dated 3/21/17 indicated the external length was zero and arm circumference was 40 cm. A review of Resident 28's TAR dated 3/21/17 indicated the external length was 0.5 cm and arm circumference was 18 inches, equal to 45.7 cm. 4. A review of Resident 29's clinical record indicated the resident was admitted to the facility on 4/1/17 with a PICC inserted in the right upper arm. Review of Resident 29's TAR dated 4/2/17 indicated the external length was 0.2 cm. There was no baseline measurement available to compare whether the PICC remained in place. Review of Resident 30's clinical record indicated the resident admitted to the facility on 3/27/17 with a PICC to her right upper arm. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 27 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 There was no baseline information regarding her PICC measurement. 5. Review of Resident 30's TAR indicated that on 3/28/17, the external length of the resident's PICC was 2 cm and on 3/29/17 the external length was unknown. During an interview with registered nurse E (RN E) on 4/3/17 at 4:05 p.m., she reviewed the clinical records of Residents 21, 28, 29, and 30 regarding PICC measurement. She stated staff measured the external length and arm circumference for PICC use to ensure the placement. She stated staff should obtain the original length left at insertion from an acute care hospital upon admission. She stated any differences should be reported to the physicians, and nurses who measured had all different ways to measure the length. During an interview with the director of nursing (DON) on 4/4/17 at 1 p.m., he stated nurses had different ways to measure PICC's external length and arm circumference. He stated when there was any difference identified in measurement of more than 2 cm, the physician should be notified. He stated the facility did not have a policy and procedure regarding how to measure PICC's external length and arm circumference and when staff should notify physicians.

F329 SS=D DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.45(d)(e)(1)-(2)

F329 05/04/2017 483.45(d) Unnecessary Drugs-General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-(1) In excessive dose (including duplicate drug FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 28 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure residents were free from unnecessary drugs when the behavior of one of 24 sampled residents (10) was not monitored. This failure had the potential for staff to inaccurately evaluate the effectiveness or ineffectiveness of the medication. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 29 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 Findings: Review of Resident 10's clinical record indicated his diagnosis included major depressive disorder (mental disorder characterized by a persistent feeling of sadness or a lack of interest). Review of the 04/2017 physician order indicated Paroxetine (an antidepressant) was started on 11/1/16 for depression for verbalization of sadness related to left hand contracture (abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching). It also indicated to monitor for episodes of depression as evidenced by verbalization of sadness related to left hand contracture every shift (every eight hours). Review of the Interdisciplinary Team (IDT) Notes titled Psychosocial Psychotropic/Gradual Dose Reduction (GDR)/Behavior Management with the completion date of 1/22/17 indicated twice under Behavioral Summary that Resident 10 had "no behaviors" exhibited for depression as evidenced by verbalization of sadness related to left hand contracture. It also indicated "no monitoring" and "na" under Summary of Target Behavior. During a concurrent record review of the Medication Administration Record (MAR) for 11/2016, 12/2016, 1/2017, 2/2017, 3/2017, 4/2017, and an interview with the assistant director of nursing K (ADON K) on 4/5/17 at 10:30 a.m., she stated the task was not in place to record the frequency of the behavior monitoring of depression for Paroxetine since November 2016. She reviewed the MAR and stated only the nurses' initials were documented and there was no frequency documented for the number of episodes the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 30 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 behavior was exhibited by Resident 10. During a telephone interview with the pharmacist consultant (CP) on 4/5/17 at 3:50 p.m., she stated behaviors have to be quantified to evaluate the effectiveness of the medication. She reviewed the MAR and was unable to find documentation of the frequency for the behavior monitoring of depression for Paroxetine. Review of the facility's 2001 policy revised 04/2007 "Behavior Assessment and Monitoring", indicated the staff would document onset, duration and frequency of problematic behaviors.

F332 SS=E FREE OF MEDICATION ERROR RATES OF 5% OR MORE CFR(s): 483.45(f)(1)

F332 05/04/2017 (f) Medication Errors. The facility must ensure that its(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 16% medication error rate when four medication errors occurred out of 25 opportunities during the medication passes. This failure resulted in residents not getting their medications as ordered by physicians. Findings: 1. Review of Resident 26's physician order dated 3/29/17, indicated Metamucil (laxative) 1 teaspoon by mouth twice a day. The physician order included a special instruction to mix 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 31 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 tablespoon of Metamucil in 8 ounces (oz, unit of volume) water. During an observation on 4/3/17 at 8:25 a.m., licensed vocational nurse A (LVN A) prepared Resident 26's Metamucil. He stated he put "15 milliliters" (mL, unit of volume) of Metamucil in a cup of water. During a concurrent observation, Resident 26 stated the water which was mixed with the Metamucil, was "too thick" and refused to drink it. During a concurrent interview, LVN A stated he should have mixed 1 teaspoon of Metamucil and it would be 5 mL, instead of 15 mL. During an interview on 4/3/17 at 9 a.m., LVN A measured the cup he used to mix Metamucil and water. He stated the cup could contain 150 mLwater. He stated he should mix Metamucil in 8 oz which was 240 mL water as prescribed. During an interview with the assistant director of nursing F (ADON F) on 4/4/17 at 9:50 a.m., she stated the physician ordered 1 teaspoon of Metamucil for Resident 26 and the special instruction in the order was entered wrong. 2. Review of Resident 27's physician order dated 3/19/17, indicated metformin (a diabetes medicine 1000 milligrams (mg, unit of measure) to be administered with food. During an observation on 4/3/17 at 9:25 a.m., LVN A administered Resident 27's metformin with water. There was no meal tray present or food given with the metformin. During an interview on 4/3/17 at 1:40 p.m., LVN A stated he should have administered the metformin with a meal or any food as ordered. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 32 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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. Review of Resident 11's physician order dated 1/8/17 indicated Combigan (an eye drop to reduce eye pressure) one drop to the left eye. During an observation on 4/3/17 at 9:45 a.m., LVN B administered Combigan to both of Resident 11's eyes. During an interview on 4/3/17 at 1:15 p.m., LVN B stated she administered the Combigan to both eyes. LVN B stated she should have administered the Combigan to the resident's left eye as ordered, or called the physician to obtain an order to administer in both eyes. 4. Review of Resident 18's physician order dated 6/14/16 indicated phenytoin suspension (125mg/5mL) 400mg (16 mL) for seizure. During an observation on 4/3/17 at 4:20 p.m., LVN C prepared 5 mL of Resident 18's phenytoin suspension. During an interview on 4/3/17 at 5:20 p.m., LVN C stated she should have administered 16 mL of phenytoin suspension to Resident 18. A review of the facility's 2001 policy "Administering Oral Medications", revised 4/2007, indicated to verify a physician's medication order prior to administering medications. It indicated to check the medication dose, re-check to confirm the proper dose, and prepare the correct dose of medication. Review of Lexicomp online (online.lexi.com, web-based drug information resource) indicated to administer metformin with a meal to decrease gastrointestinal upset. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 33 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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

F333 RESIDENTS FREE OF SIGNIFICANT MED ERRORS CFR(s): 483.45(f)(2)

F333 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/04/2017 483.45(f) Medication Errors. The facility must ensure that its(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (18) was free from a significant medication error when Resident 18 was administered a wrong dose of an antiseizure medication (phynitoin). This failure had the potential to adversely affect the resident. Findings: Review of Resident 18's physician orders dated 6/14/16, indicated phenytoin suspension (125mg/5mL) administer 400mg (16 mL) for seizure. During an observation on 4/3/17 at 4:20 p.m., LVN C prepared 5 mL phenytoin suspension and administered it to Resident 18. During an interview on 4/3/17 at 5:20 p.m., LVN C stated she should have administered 16 mL of phenytoin suspension to Resident 18. Review of the facility's 2001 policy "Administering Oral Medications" revised 4/07, indicated to check the medication dose, recheck to confirm the proper dose, and prepare the correct dose of medication. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 34 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd Los Gatos, CA 95032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F371 FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) SS=E ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/04/2017 (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. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain the kitchen under sanitary conditions when 1. a floor fan with a gray substance was placed next to the cleaned glasses, cups, and bowls; 2. the mixture machine and the beater had black substances on them; 3. the can opener had a black substance on the blade and its surrounding area. These failures had the potential to cause food-borne illness and contaminate the facility's food sources. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 35 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 Findings: 1. During an initial kitchen tour with acting dietary supervisor U (ADS U), on 4/3/17, at 7:34 a.m., a floor fan had gray substances and was placed next to the cleaned glasses, cups and bowls rack. ADS U validated this observation. During an interview with assistant dietary supervisor V (ADS V), on 4/3/17, at 7:55 p.m., he stated the maintenance department should clean the fan, the floor fan should not be placed next to the cleaned glasses and cups. 2. During an initial kitchen tour with ADS U, on 4/3/17, at 8:15 a.m. and 8:23 a.m., the mixture machine had black substances on its connector area (the area connects to the beater). The metal food beater (kitchen utensil used to stir, whisk or beat the food) had a black substance on its handle area (the area attaches to the mixture machine to mix the food). The metal beater was inside a half-full bowl of brown pancake mix. ADS U validated these observations. During an interview with Cook W on 4/3/17, at 8:16 a.m., she stated she "only" wiped the mixture machine connector area with a towel before she used the mixture machine to mix the pancake in the morning. Review of the facility's undated policy, "ELECTRICAL FOOD MACHINES", indicated the the facility should maintain all food machines in sanitary condition. 3. During an initial kitchen tour with ADS U, on 4/3/17, at 8:23 a.m., the can opener had black substances on the blade and its surrounding area. ADS U validated this observation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 36 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 registered dietitian (RD) on 4/3/17, at 11:50 a.m., she stated the dirty floor fan should not be placed next to the cleaned glasses rack. The RD stated staff should clean the mixture machine connector and beater when they were dirty, should clean the can opener blade and its surrounding area when they were dirty. Review of facility's undated policy, "CAN OPENER AND BASE", indicated the staff should clean the can opener "thoroughly" each work shift and more frequently when necessary. Review of the FDA 2013 Food Guideline Chapter 4 indicated the can openers' cutting or piecing parts should be protected from manual contact, dust, insects, rodents, and other contamination.

F428 SS=D DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON CFR(s): 483.45(c)(1)(3)-(5)

F428 05/04/2017 c) Drug Regimen Review (1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. (3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 37 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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) The pharmacist must report any irregularities to the attending physician and the facility’s medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility’s medical director and director of nursing and lists, at a minimum, the resident’s name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident’s medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident’s medical record. (5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, consultant pharmacist M (CP M) failed to identify a medication irregularity during the medication regimen review (MRR) for one of 24 sampled residents (10), when CP M did not identify that a specific target behavior for an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 38 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 antidepressant was not monitored. This failure had the potential for staff to inaccurately evaluate the effectiveness or ineffectiveness of the medication and placed the resident at risk for receiving unnecessary drugs. Findings: Review of Resident 10's clinical record indicated his diagnosis included major depressive disorder (mental disorder characterized by a persistent feeling of sadness or a lack of interest). Review of Resident 10's physician order indicated Paroxetine (also known as Paxil) was started on 11/01/2016 for depression for verbalization of sadness related to left hand contracture (abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching). It also indicated Resident 10 also had a physician's order, started on 11/01/2016, to monitor episodes of depression as evidenced by verbalization of sadness related to left hand contracture every shift (eight hours). Review of the Interdisciplinary Team (IDT) Notes, titled Psychosocial Psychotropic/Gradual Dose Reduction (GDR)/Behavior Management, with the completion date of 01/22/17, indicated twice under Behavioral Summary that Resident 10 had "no behaviors" exhibited for depression. It also indicated "no monitoring" and "na" under Summary of Target Behavior. Review of the MRR with the completed dates of 11/28/2016, 11/30/2016, 1/5/2017, 2/7/2017, and 3/31/2017 indicated no irregularities were reported to the staff or physician regarding the behavior monitoring for depression to support the use of Paroxetine. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 39 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 concurrent record review of the Medication Administration Record (MAR) for 11/2016, 12/2016, 1/2017, 2/2017, 3/2017, and 4/2017 and an interview with assistant director of nursing K (ADON K) on 4/5/17 at 10:30 a.m., she stated the task was not in place to record the frequency for the behavior monitoring of depression for Paroxetine since November 2016. She stated only the nurses' initials was documented and there was no frequency documented for the number of episodes the behavior was exhibited by Resident 10. During a concurrent record review and telephone interview with CP M on 4/5/17 at 3:50 p.m., she stated behaviors have to be quantified to evaluate the effectiveness of the medication. She stated she reviewed the behavior monitoring monthly for the psychotropic review to identify if it is appropriate and would go to the MAR to look for how many times a behavior occured in the prior 14 days. She reviewed the MAR and was unable to find documentation of the frequency for the behavior monitoring of depression for Paroxetine. She stated staff had to indicate how a behavior happened and quantify the behavior to evaluate effectiveness but it was not being done. Review of the Clinical Pharmacist Job Description, dated 2013, indicated the pharmacist must "perform for Centers for Medicare and Medicaid Serices (CMS) required Medication Regimen Review as required by law" and "identify patients receiving medication known to have high potential of risks and manages associated risk by improving monitoring."

F431 SS=D DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS FORM CMS-2567(02-99) Previous Versions Obsolete

F431 Event ID: MWR711 05/04/2017 Facility ID: CA070000003 If continuation sheet 40 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 CFR(s): 483.45(b)(2)(3)(g)(h) The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (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. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (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. (h) Storage of Drugs and Biologicals. (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 41 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 authorized personnel to have access to the keys. (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 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 all controlled substance (CS) medications (medications with a high risk for abuse and addiction) were accounted for appropriately during a review of random CS records for one of 24 sampled residents (21) and one non-sampled resident (25). Staff signed out the CS medication from the inventory sheet without subsequent documentation in the Medication Administration Record (MAR) as given. These failures had the potential to result in the abuse or the misuse of controlled medications. Findings: Review of Resident 21's Controlled Substance Accountability Sheet (CSAS) indicated Norco (pain medication) 2 tablets were taken out on 3/21/17 at 5 a.m., 3/23/17 at 11:55 p.m., 4/1/17 at 5:20 a.m., and 4/1/17 at 4:22 p.m. Review of Resident 21's MAR, dated 3/2017, indicated there was no documented evidence Norco was administered to the resident on 3/21/17 and 3/23/17. Review of Resident 21's MAR, dated 4/2017, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 42 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 indicated there was no documented evidence Norco was administered on 4/1/17 at 5:20 a.m., and 4/1/17 at 4:22 p.m. Review of Resident 25's CSAS indicated Tramadol (pain medication) was taken out on 3/28/17 at 6 a.m. and 3/29/17 at 10 a.m. Review of Resident 25's MAR, dated 3/2017, indicated there was no documented evidence the resident received Tramadol on 3/28/17 at 6 a.m. and 3/29/17 at 10 a.m. During an interview with assistant director of nursing D (ADON D) on 4/3/17 at 11:10 a.m., he reviewed the CSAS and the MAR for Residents 21 and 25 and confirmed the discrepancies between the documentation. He stated the CSAS and the MAR should be matched for the use of CS medications. Review of the facility's 2001 policy "Administering Pain Medication", revised 4/2009, indicated to document a medication used in the resident's medical record. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 43 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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

F457 BEDROOMS ACCOMMODATE NO MORE THAN 4 RESIDENTS CFR(s): 483.90(e)(1)(i)

F457 05/04/2017

F458 05/04/2017 SS=B PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (e)(1) Bedrooms must-(e)(1)(i) Accommodate no more than four residents;. For facilities that receive approval of construction or reconstruction plans by State and local authorities or are newly certified after November 28, 2016, bedrooms must accommodate no more than two residents. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure one of 62 resident rooms (509) accommodated no more than four residents per room. This failure had the potential to compromise the quality of life and the quality of care the residents received. Findings During multiple observations conducted in Room 509, on 4/5/17, and 4/6/17, the room had five beds with four residents. Residents and staff were observed to move freely and safely with no issues noted during residents' care. During interviews with randomly selected residents and staff, there were no quality of care issues identified concerning the size of the room and the number of occupants. Recommended the waiver remain in effect.

F458 SS=B BEDROOMS MEASURE AT LEAST 80 SQ FT/RESIDENT CFR(s): 483.90(e)(1)(ii) (e)(1)(ii) Measure at least 80 square feet per FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 44 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to provid at least 80 square feet per resident for 16 of 62 resident rooms. This failure had the potential to compromise the quality of life and the quality of care the residents received. Findings: Room numbers and measurements per resident were as follows: Rm # # of Beds/Rm. Total Sq. Ft. Sq. Ft./Bed 304 3 222 74 404 2 142 71 406 2 140 70 407 2 142 71 408 2 146 73 409 2 142 71 410 2 147 73.5 411 2 144 72 412 2 148 74 414 2 144 72 415 2 147 73.5 416 2 144 72 500 2 144 72 504 2 144 72 506 2 144 72 511 3 228 76 During the survey, residents were observed in their rooms. The nursing care and services were not affected by the shortage of space. The closets and storage spaces were sufficient to accommodate the needs of the residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 45 of 46 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: _______________ 055798 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd 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 residents and staff verbalized no complaints or concerns regarding space and privacy. Recommend the waiver remain in effect. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MWR711 Facility ID: CA070000003 If continuation sheet 46 of 46