Other·January 3, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a recertification survey conducted on 12/19/19. The facility was licensed for 59 beds. The census at the time of the survey was 51. The sample size was 13. For F686 and F689 the scope and severity was a "G". Also, three (3) Class "B" citations were issued (see F623 with F625, F686 and F689). Representing the California Department of Public Health: 38174 Health Facilities Evaluator Nurse; 34432, Health Facilities Evaluator Nurse; and 36623 Health Facilities Evaluator Nurse.

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 01/13/2020 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and 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: 1U2711 Facility ID: CA070000778 If continuation sheet 1 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 2 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide written notification to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 3 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 long-term care ombudsman (person who routinely visits the facility and advocates for the residents) when three of five sampled residents (Residents 32, 4, and 34) were transferred to the acute care hospital. This failure had the potential to result in the residents not having an advocate who could inform them of their admission, transfer, and discharge rights and options. Findings: Review of Resident 32's clinical record indicated the facility transferred her to an acute care hospital on 10/25/19 and 11/28/19. There was no documentation in the clinical record indicating the facility informed the ombudsman of these transfers. Review of Resident 4's clinical record indicated the facility transferred her to an acute care hospital on 8/16/19. There was no documentation in the clinical record indicating the facility informed the ombudsman of this transfer. Review of Resident 34's clinical record indicated the facility transferred him to an acute care hospital on 8/28/19. There was no documentation in the clinical record indicating the facility informed the ombudsman of this transfer. During an interview with the admission manager (AM) on 12/19/19 at 12:40 p.m., he confirmed the facility did not have the process to notify the long-term care ombudsman when residents were transferred to an acute care hospital, but only when residents were discharged from the facility. A review of the facility's "Sending Required Transfer/Discharge Notices to your Local LongTerm Care Ombudsman Program", dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 4 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 10/2017, indicated facilities were required to send copies of all notices related to facility initiated transfers and discharges ... when a resident was temporarily transferred on an emergency basis to an acute care facility, notice of transfer may be provided to the resident and resident representative ... copies of these notices can also be sent to the LTCOP when practicable, such as in a monthly list.

F625 SS=D Notice of Bed Hold Policy Before/Upon Trnsfr CFR(s): 483.15(d)(1)(2)

F625 01/13/2020 §483.15(d) Notice of bed-hold policy and return§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any; (iii) The nursing facility's policies regarding bedhold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and (iv) The information specified in paragraph (e) (1) of this section. §483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 5 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide a written notice of bed hold (written documentation specifying the duration the facility will hold a resident's bed) for four of five sampled residents (Residents 21, 32, 4, and 34). This failure had the potential to limit the rights of the resident or his responsible party (RP, a person who is accountable in making decisions on behalf of the resident) to know the duration of a bed-hold and permitting for return to the facility. Findings: Review of Resident 21's clinical record indicated on 12/2/19, Resident 21 was transferred to an acute care hospital for evaluation after a chemotherapy (type of cancer treatment that uses one or more anticancer drugs) appointment. The record had no documentation or evidence that a written notice of bed-hold was given to the resident or to the resident's family or RP. During an interview with the admission manager (AM) on 12/18/19 at 1:27 p.m., he confirmed the bed hold notification was not issued. Review of Resident 32's clinical record indicated Resident 32 was transferred to an acute care hospital on 10/25/19 and 11/28/19. The record had no documentation or evidence that a written notice of bed-hold was given to the resident or to the resident's family or RP. Review of Resident 4's clinical record indicated the facility transferred her to an acute care hospital on 8/16/19. The record had no documentation or evidence that a written notice of bed-hold was given to the resident or to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 6 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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's family or RP. Review of Resident 34's clinical record indicated the facility transferred him to the acute care hospital on 8/28/19. The record had no documentation or evidence that a written notice of bed-hold was given to the resident or to the resident's family or RP. During an interview with the AM on 12/19/19 12:40 p.m., the AM was not able to provide evidence bed hold notification was issued for Residents 32, 4, and 34. A review of the facility's Bed Hold Notification/Authorization Form, dated 8/21/17, indicated the facility would provide the resident or his/her legal representative with written notice of the resident's right to a bed-hold upon admission, and at the time of the resident transfer to the acute hospital.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 01/18/2020 §483.21(b) Comprehensive Care Plans §483.21(b)(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 (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 7 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 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 observation , interview and record review, the facility failed to develop a comprehensive care plan to address the use of antibiotics (medicines that help stop infections caused by bacteria) and a peripherally-inserted central catheter (PICC, a thin, flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart and used to give intravenous fluids, blood transfusions and other drugs) for one sampled resident (Resident 105). These failures had the potential to result in the inability to identify the residents' individualized care issues and implement person-centered care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 8 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 105's clinical record indicated he was admitted to the facility on 11/23/19 with a diagnoses including infection and inflammatory reaction due to internal left hip prosthesis (an artificial device to replace a missing or impaired part of the body). Review of Resident 105's Order Summary Report dated 11/30/19, indicated change dressing to PICC site every seven days and as needed soiled or dislodged. Resident 105 had an order for Ceftriaxone (a type of antibiotic) 2 grams (gm, a unit measurement) intravenously (IV, the giving of something such as drugs into a vein) daily and Vancomycin (a type of antibiotic) 1000 milligram (mg) IV every 12 hours for infection and inflammatory reaction due to internal left hip prosthesis. Review of Resident 105's care plan did not address the use of a PICC line and antibiotics. During an observation on 12/16/19 at 8:54 a.m., Resident 105 had a PICC line on his right upper arm. During an interview and concurrent record review with the interim director of nursing (IDON) on 12/17/19 at 12:28 p.m., the IDON confirmed there was no care plan to address PICC line and the use of the antibiotics. The IDON acknowledged a care plan should have been developed to address PICC line and the use of the antibiotics. A review of the facility's policy," Care Plans Comprehensive", dated 10/2010, indicated an individualized comprehensive care plan included measurable objectives and timetables to meet the resident's medical, nursing, mental FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 9 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 psychological needs was developed for each resident.

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 01/18/2020 §483.21(b) Comprehensive Care Plans §483.21(b)(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 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 observation, interview, and record review, the facility failed to ensure the comprehensive interdisciplinary plan of care for three of four sampled residents (Residents 15, 4, and 33) was revised to reflect the resident's current care needs and interventions. This FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 10 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 posed the risk of not providing residents with individualized and person-centered care. Findings: 1. Review of Resident 15's clinical record indicated she was admitted to the facility on 8/1/19 with diagnoses including dementia ( group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life) without behavioral disturbance. Review of Resident 15's care plan dated 8/1/19, indicated she needed assistance with activities of daily living (ADL's, basic tasks of everyday life i.e. eating, bathing, dressing) related to weakness due to recent illness. During observations on 12/16/19 at 11:00 a.m. and 12/17/19 at 7:42 a.m., Resident 15 was in bed with her eyes closed. During an interview with licensed vocational nurse G (LVN G) on 12/17/19 at 7:42 a.m., he stated Resident 15 had been refusing to get up, refusing to take medications, and usually was non-verbal for quite a long time. During an interview with the interim director of nursing (IDON) on 12/17/19 at 12:19 p.m., she reviewed Resident 15's care plan. The IDON acknowledged Resident 15's behaviors as described above, and stated Resident 15 should have a care plan to address her behavior. 2. Review of Resident 4's clinical record indicated diagnoses of dementia (decline in mental abilities and memory affecting judgment and behavior), muscle weakness, difficulty in walking and intracapsular fracture of right femur (hip joint). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 11 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd Los Gatos, CA 95032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 4's "Post Fall Assessments", indicated she had falls on 4/17/19, 6/11/19, 6/19/19, 8/1/19, 8/14/19, and 8/15/19. During a review of Resident 4's 2019 fall care plan (CP, a written document which provides a means of communication among healthcare providers to achieve health care outcomes) indicated there were no new interventions after the falls on 6/11/19 and 6/19/19. During an interview and record review with the interim director of nursing (IDON) on 12/18/19 at 10:15 a.m., she stated the post-fall committee did not recommend new interventions for the falls of 6/11/19 or 6/19/19, so the fall care plan was not revised. 3. Review of Resident 33's clinical record indicated she was admitted to the facility on 3/11/19 with diagnoses including heart failure. She had falls on 3/16/19, 4/23/19, 5/5/19, and 10/30/19. A review of Resident 4's post-fall "Committee Reviews (CR)" indicated the following recommendations and interventions: 1) 3/20/19: Check the resident's brief every two hours and as needed and place sign in room with a picture of call light and the words "please press call light for help." 2) 4/24/19: Offer the resident to sit in wheelchair rather than the edge of the bed and if the resident chooses to sit at the edge of the bed, ensure that the bed is at an appropriate height and the resident is supported. 3) 5/6/19: Apply a dycem (non-slip material) to wheelchair to prevent sliding. Review of Resident 33's fall care plan indicated the committee recommendations were not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 12 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 included as interventions to prevent falls. During an interview on 12/17/19 at 1:28 p.m., the IDON stated the new interventions were not carried over to the long term fall care plan. The IDON stated the new interventions were deleted and confirmed the care plan was not revised to include the new interventions. A review of the facility's policy,"Care PlansComprehensive", dated 10/2010, indicated assessments of residents are ongoing and care plans were revised as information about the resident and the resident's condition change.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 01/13/2020 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to follow their pressure ulcer (PU, ijuries to skin and underlying tissue resulting when soft tissue is compressed between a bony prominence and an external surface for a long period of time) prevention FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 13 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 policy for one of two sampled residents (Resident 16) with a PU. The facility did not plan for or implement the intervention to protect Resident 16's left heel from undue pressure by keeping it off of the bed. This failure resulted in Resident 16 developing a facility-acquired Stage III PU (involves full-thickness skin loss and extends into the tissue beneath the skin, forming a small crater) on his left heel. Findings: Review of Resident 16's clinical record indicated he was admitted to the facility on 10/14/19 with diagnoses of rhabdomyolysis (a serious syndrome due to muscle injury which results in the death of muscle fibers and their release into the bloodstream) and Type II diabetes (a chronic condition which affects the way the body processes blood sugar). Review of Resident 16's "Nursing Admission Assessment" dated 10/14/19, indicated on initial assessment Resident 16 did not have a wound on his left heel. Review of Resident 16's "Minimum Data Set" (MDS, an assessment tool)" dated 10/15/19, indicated Resident 16 was immobile in bed and required extensive assistance of one person to turn side-to-side and to position self while in bed. The same MDS indicated Resident 16 did not have any pressure wounds when admitted and had a brief interview of mental status (BIMS) score of 9 (scores of 8-12 points indicates moderately impaired thinking and memory). A review of Resident 16's "Care Plan" dated 10/14/19, indicated Resident 16 was at risk for impairment of skin integrity on admission. The Care Plan indicated there was no intervention written to float heels (keep heels off of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 14 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 bed) until 11/23/19, after the discovery of Resident 16's left heel PU. Review of Resident 16's "Committee Review Progress Notes" dated 11/26/19 at 10:30 a.m., indicated the committee met to discuss Resident 16's newly acquired left heel pressure ulcer discovered on 11/24/19. The committee noted Resident 16 had been at risk for pressure injury and recommended to keep feet elevated off of the bed at all times while in bed. Review of the physician wound service (PWS) "Initial Wound Evaluation and Management Summary" dated 11/27/19, indicated Resident 16 had a Stage III PU of the left heel for at least seven days duration (11/20/19). The PWS recommended to off-load heel wound (keep left heel up and not touching the bed) and to reposition resident according to facility protocol. Review of Resident 16's "Treatment Administration Record (TAR)" dated October through December, indicated Resident 16 was turned every two hours since admission beginning on 10/16/19 but there was no indication Resident 16's heels were offloaded from the bed. During an observation on 12/18/19 at 10:50 a.m., Resident 16 was lying in bed with lower legs elevated with two pillows and received assessment and treatment to his left heel by the PWS. PWS confirmed Resident 16's left heel Stage III PU developed after he was admitted to the facility. During an interview with the interim director of nursing (IDON) on 12/19/19 at 9:39 a.m., she stated the facility identified Resident 16's left heel wound was preventable. The IDON stated the conference team identified the problem of Resident 16's left heel wound and ordered a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 15 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 physician led inservice regarding prevention of pressure wounds and how Resident 16's pressure wound could have been prevented, held on 12/11/19. The IDON stated staff had not taken measures to offload Resident 16's heels and prevent the development of his pressure wound. The DON stated going forward residents at risk for pressure ulcers would be provided with foam boot heel protectors to help offload feet while in bed. Review of the facility's 2010 policy, "Prevention of Pressure Ulcers", indicated pressure ulcers are usually formed when a resident remains in the same positon for extended periods of time causing increased pressure and a decrease in blood circulation to the area ... a common site is where the bone is near the surface of the body including the heels ... for residents who required assistance while in bed, change position at least every two hours and off-load heels (keep heals off of the bed.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 01/13/2020 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to plan for and implement new post-fall interventions to prevent falls for one of six sampled residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 16 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 4) with falls. These failures resulted in Resident 4 falling six times between 4/17/19 and 8/15/19, and on the sixth fall, Resident 4 sustained a right hip fracture. Findings: A review of Resident 4's clinical record indicated diagnoses of dementia (decline in mental abilities and memory affecting judgment and behavior), muscle weakness, difficulty in walking and intracapsular fracture of right femur (occurs when the top part of the femur (leg bone) is broken; the ball on the top of the femur has broken off at its junction within the hip joint). A review of Resident 4's general acute care hospital (GACH) emergency department "History and Physical (H&P)" dated 8/16/19, indicated Resident 4 was admitted to the GACH for treatment of a right hip fracture resulting from a fall on 8/15/19. A review of Resident 4's "Progress Notes (PN)" dated 8/24/19 at 7:59 a.m., indicated Resident 4 was readmitted to the facility on 8/23/19 with a diagnosis of open reduction and internal fixation (ORIF, a surgery in which the doctor makes an incision (cut) to reach the bone and move it back into normal position) following a right intracapsular femur fracture. The PN further indicated Resident 4 had a right hip incision (surgical cut) covered by a gauze dressing. A review of Resident 4's minimum data set (MDS, an assessment tool) dated 5/31/19, indicated a brief interview of mental status (BIMS) score of 0 (scores of 0 indicate resident was not able to answer questions which tested thinking and memory correctly). The same MDS indicated Resident 4 required the physical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 17 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 assistance of one person to provide weight bearing support to transfer between the bed and the wheel chair (WC) and between the WC and the toilet. The same MDS indicated Resident 4 was able to use the walker and the WC for mobility. A review of Resident 4's "Morse Fall Scale" dated 5/30/19, indicated Resident 4 scored 80 (scores of 45 or higher indicate a high risk for falls). A review of Resident 4's "Post Fall Assessments", indicated the following: 1) 4/17/19: Unwitnessed fall from bed with no injury; resident wheels herself to the bathroom and does not call for help. 2) 6/11/19: Unwitnessed fall from bed resulting in a bleeding skin tear on the back of her left hand, resident was incontinent during event. 3) 6/19/19: Unwitnessed fall to floor near bathroom with no injury; wheel chair (WC) next to resident. 5) 8/14/19: Unwitnessed fall from bed with no injury while attempting to get into her WC. A review of Resident 4's post-fall "Committee Reviews (CR)", indicated the following recommendations and interventions: 1) 4/19/19: Provide in-service training to team to keep WC locked when not in use. 2) 6/12/19: Continue the rehabilitation nursing assistant (RNA) program and anticipate toileting needs; toilet resident before breakfast. 3) 6/21/19: Continue RNA program and anticipate toileting needs. 4) 8/5/19: Found on floor in sitting position 10: 40 p.m. Continue RNA program and anticipate toileting needs; check on resident hourly and toilet resident before bed. 5) 8/16/19: Post-Fall CR for fall of 8/14/19 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 18 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 8/15/19 recommendations: Upon return from GACH Resident 4 will transfer to a room close to the nurse's station where she will always be in site of staff in the station. During a review of Resident 4's 2019 fall care plan (CP, a written document which provides a means of communication among healthcare providers to achieve health care outcomes) indicated the following interventions to prevent falls: CP interventions in place prior to the above committee recommendations: Anticipate and meet Resident 4's needs (Initiated 2/26/17). Increase RNA program to five days per week (Initiated on 2/26/17; was not cancelled but was repeated during a revision on 4/17/19). Keep wheelchair locked while not in use (Initiated on 2/26/17; was not cancelled but was repeated during a revision on 4/17/19). New CP interventions initiated after Resident 4's falls: 1) Fall of 4/17/19: In-service team to keep WC locked while not in use. 2) Fall of 6/11/19: Date of fall and new interventions were not found on the CP. 3) Fall on 6/19/19: New interventions were not found on the CP 4) Fall on 8/1/19: Hourly rounding for safety; toilet resident before going to bed. 5) Fall on 8/14/19: Make sure bed is in locked position The resident needs activities that minimize the potential for falls while providing diversion and distraction. 6) Fall on 8/15/19: Change resident's room to a room closer to the nurses' station. A review of Resident 4's "Admission Record", indicted Resident 4 was readmitted to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 19 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 facility to Room 2 on 8/23/19 and Resident 4's previous location was Room 1. During an observation on 12/18/19 at 9 a.m., Room 1's location was observed at the end of a hall, farthest from the nurse's station. Room 2's location was observed across from and in view of the nurse's station. During an interview with CNA H on 12/18/19 at 9:45 a.m., she stated she worked with Resident 4 before her injury of 8/15/19. CNA H stated she did not remember nurses telling her to check on Resident 4 every hour. CNA H stated the CNA's were busy and were not able to watch on her all the time. During an interview and record review with the interim director of nursing (IDON) on 12/18/19 at 10:15 a.m., she stated the post-fall committee should have recommended new interventions to prevent Resident 4 from having further falls for the falls on 6/11/19 or 6/19/19. The IDON stated toileting Resident 4 before breakfast and before bed were not new interventions, but were usual expectations of a certified nursing assistant (CNA). The IDON stated interventions which could have been recommended by the committee to prevent further falls were: to move Resident 4 closer to the nurses' station at an earlier date, to order physical therapy (PT) or occupational therapy (OT) for a strengthening evaluation and to provide written instructions of interventions to the CNA. The IDON stated the facility was unable to track if Resident 4 was actually checked on or toileted more than one time per shift due to the limitations of the facility's electronic documentation system which only allowd the CNA to document toileting and safety monitoring one time per shift. During an interview with CNA C on 12/18/19 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 20 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 1:30 p.m., she stated she knew Resident 4 well and was often assigned to her. CNC C stated before Resident 4's hip injury of 8/15/19, the nurses did not tell her to check on or toilet Resident 4 every hour or any other time frame. CNA C stated she was often busy with other residents and unable to check on Resident 4. CNA C stated Resident 4 was confused and never used her call light. CNA C stated an order for safety checks every 15 minutes and Resident 4's move to a room closer to the nurse's station may have helped to prevent Resident 4's falls and injury. CNA C stated Resident 4's room used to be Room 1 located at the end of the hall farthest from the nurses station. A review of Resident 4's MDS dated 8/30/19, indicated post-injury of Resident 4 required extensive assistance with two people for toileting and did not walk in or out of her room. Review of the facility's 2007 policy "Falls and Fall Risk, Managing", indicated if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant ... if underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable.

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 01/18/2020 § 483.25(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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 21 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to implement their policy and procedures for the use of a continuous positive airway pressure (CPAP, a treatment that uses mild air pressure to keep your breathing airways open) machine for one sampled resident (Resident 107) when Resident 107 was using the CPAP machine without a physician's order. These failures had the potential to result in ineffective CPAP therapy. Findings: Review of Resident 107's Admission Record, indicated she was admitted to the facility on 12/10/19 with diagnoses of acute and chronic respiratory failure (a condition in which not enough oxygen passes from your lungs into your blood) with hypoxia (deficiency in the amount of oxygen reaching the tissues). Review of Resident 107's Order Summary Report did not include a CPAP order. Review of Resident 107's Admission Assessment, dated 12/10/19, indicated she was oriented to person, place, time, and situation. During an observation and concurrent interview with Resident 107 on 12/16/19 at 9:46 a.m., Resident 107 had a CPAP machine on her bedside table. Resident 107 stated she had been using the machine since she arrived in the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 22 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 and concurrent record review with the interim director of nursing (IDON) on 12/17/19 at 12:30 p.m., the IDON confirmed Resident 107 did not have an order for the use of CPAP which would include the type of setting and frequency. A review of the facility's policy, "CPAP/BiPAP Support", dated 10/2010, indicated to set mode CPAP settings on the machine as prescribed. Document time CPAP was started and duration of the therapy.

F697 SS=D Pain Management CFR(s): 483.25(k)

F697 01/18/2020 §483.25(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. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure pain management was provided consistent with a person-centered care plan and the resident's goals and preferences to one of three residents (Resident 213). This failure had the potential to result in ineffective pain management. Findings: Review of Resident 213's clinical record indicated she was admitted to the facility on 12/6/19 with diagnoses including surgery to the genitourinary system (organs in the reproductive system and the urinary system [includes kidney and bladder]). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 23 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd Los Gatos, CA 95032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 213's physician orders indicated the following: 1. Assess pain level on a scale of 1 to 10 every shift: mild (1-3), moderate (4-6), severe (7-9), very severe (10); 2. Acetaminophen (pain medication) tablet, give 650 milligrams (mg, unit of measurement) by mouth every four hours as needed for mild pain 1-3; 3. Oxycodone-acetaminophen (narcotic pain medication) tablet 10-325 mg, give one tablet by mouth every four hours as needed for severe pain 7-10; and 4. Tylenol with Codeine #4 (narcotic pain medication) tablet 300-60 mg, give one tablet by mouth every four hours as needed for moderate-severe pain (7-10). Review of Resident 213's care plan for pain indicated the resident had pain related to "current illness" and neuropathic pain (nerve pain). The interventions included to administer analgesia (pain medication), monitor/document for side effects of pain medication, and notify physician if interventions are unsuccessful. Resident 213's care plan did not include nonpharmacological (without medicine) interventions to manage her pain. During an interview on 12/16/19 at 12:08 p.m., the interim director of nursing (IDON) reviewed Resident 213's orders and stated residents usually have pain medication ordered for mild, moderate, and severe pain. The IDON confirmed Resident 213's pain medication orders did not address pain with a rating of 4-6. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 24 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 12/18/19 at 11 a.m., the IDON confirmed Resident 213's care plan for pain was not resident-centered. During an interview on 12/19/19 at 1:47 p.m., Resident 213 stated she had chronic pain in her back and pain in her stomach area from surgery. She stated the medications were helping, but she preferred not to take too much medication. She stated getting out of bed helped her pain, as well as ice and heat. Review of the facility's policy, "Pain Assessment and Management," revised 10/2010, indicated staff should identify pain in the resident and develop interventions that are consistent with the resident's goals and needs.

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

F755 01/18/2020 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 25 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals when: 1. One of three emergency kits was not replaced in a timely manner; 2. An ordered medication for Resident 213 was not available; 3. The process of receipt and disposition of controlled drugs did not allow for accurate reconciliation. Findings: 1. During an observation of the medication room on 12/16/19 at 8:59 a.m. with licensed vocational nurse B (LVN B), revealed the emergency kit of intravenous (IV) supplies was opened and not sealed. LVN B stated after it is opened and the needed drug or item is removed, it should be sealed with a red tag and the pharmacy should be notified to replace the emergency kit. During an interview on 12/16/19 at 12:08 p.m., the interim director of nursing (IDON) stated the emergency kit was opened on 12/5/19. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 26 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 IDON stated it should have been replaced within 72 hours. Review of the facility's undated policy, "Emergency Kit," indicated if a medication or supply is used, the box must be reordered and all emergency box components must be resealed with a numbered tag upon opening. 2. Review of Resident 213's clinical record indicated she was admitted to the facility on 12/6/19 with diagnoses including surgery to the genitourinary system (organs in the reproductive system and the urinary system [includes kidney and bladder]). Review of Resident 213's physician orders indicated an order, dated 12/7/19, EZFE 200 capsule (polysaccharide iron complex [used to treat low levels of iron]), give 65 mg by mouth one time a day every Monday, Wednesday, and Friday for supplement. During a medication pass observation and interview on 12/16/19 at 9:53 a.m., registered nurse A (RN A) prepared medications for Resident 213. RN A stated she needed a medication from the medication room for Resident 213. RN A asked the IDON to get the medication in the medication room for her. The IDON told RN A that the medication for Resident 213 was not available. During an interview on 12/16/19 at 12:08 p.m., the IDON stated the iron complex the physician otdered was not available. She stated the pharmacy never delivered it. The IDON stated nurses were giving ferrous sulfate (type of iron). Review of the facility's policy, "Administering Medications", revised 12/2012, indicated medications must be administered in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 27 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 accordance with the orders, including any required time frame. 3. During an interview on 12/17/19 at 3:45 p.m., the IDON discussed the method of destruction of controlled drugs. The IDON stated she signed the controlled drug record when nurses gave her the unused controlled drugs. The IDON also stated the consultant pharmacist signed the controlled drug record when the controlled drug was destroyed. There was no documentation that indicated the quantity of the medication that was destroyed. The IDON confirmed the "Disposition of Unused Medication" portion of the controlled drug records were left blank. Review of the facility's policy, "Discarding and Destroying Medications", dated 4/2007, indicated "the medication disposition record must contain, as a minimum, the following information: a. The resident's name; b. Date medication destroyed; c. The name and strength of the medication; d. The prescription number (if any); e. The name of the despensing pharmacy; f. The quantity destroyed; g. Method of destruction; h. Reason for destruction; and i. Signature of witnesses."

F757 SS=D Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 01/18/2020 §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§483.45(d)(1) In excessive dose (including duplicate drug therapy); or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 28 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd Los Gatos, CA 95032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure pain management was reviewed and reassessed by the multidisciplinary team (IDT, team members from different departments involved in a resident's care) for one of six residents (Resident 4). Resident 4 had an order for narcotic pain medication (controlled drugs that in moderate doses dulls the senses, relives pain, and induces profound sleep but in excessive pain assessments dose can cause stupors, coma, and convulsions) three times a day with meals and at bedtime. This had the potential of unnecessary use of medications that could affect the resident's well-being. Findings: Review of Resident 4's Admission Record indicated she was a 95 year old, admitted to the facility on 8/23/19 with a diagnoses including fracture of right femur (the bone of the proximal part of the hind limb or thigh). Review of Resident 4's Order Summary Report FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 29 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 dated 9/5/19, indicated the following: a. Hydrocodone-acetaminophen (Norco, narcotic pain medication) 5-325 milligram (mg, a unit measurement) 0.5 tablet by mouth at bedtime for pain management. b. Hydrocodone-acetaminophen (Norco) 5-325 mg 0.5 tablet by mouth with meals for pain management c. Hydrocodone-acetaminophen (Norco) 5-325 mg 0.5 tablet by mouth every 6 hours as needed for moderate pain 4-6 (pain scale, is a numerical scale from 0 to 10. 0 means you have no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain). d. Hydrocodone-acetaminophen (Norco) 5-325 mg one tablet by mouth every 4 hours as needed for severe pain 7-10. Review of Resident 4's medication administration record (MAR) indicated the following: For the month of September 2019, Resident 4 had a pain level of 0 and was given Norco 0.5 tablet 46 times with meals and 10 times at bedtime. The other days Resident 4 had a pain level that ranged from 1 to 5. For the month of October 2019, Resident 4 had a pain level of 0 and was given Norco 0.5 tablet 72 times with meals and 9 times at bedtime. The other days Resident 4 had a pain level that ranged from 1 to 7. For the month of November 2019, Resident 4 had a pain level of 0 and was given Norco 0.5 tablet 51 times with meals and 15 times at bedtime. The other days Resident 4 had a pain level that ranged from 2 to 6. For December 1-18, 2019, Resident 4 had a pain level of 0 and was given Norco 0.5 tablet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 30 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 27 times with meals and 3 times at bedtime. The other days Resident 4 had a pain level that ranged from 1 to 5. Review of Resident 4's Inter Disciplinary Team (IDT) Care Conference, dated 12/13/19, indicated medication reconciliation was reviewed, and Resident 4 was presenting with better cooperation with care, fewer episodes of refusal and better engagement with staff. During an observation on 12/16 /19 and 12/17/19, Resident 4 was lying on her back in bed with her eyes closed. During an interview with the interim director of nursing (IDON) on 12/19/19 at 8:07 a.m., she reviewed Resident 4's MAR. The IDON stated Resident 4's had an increase behavior for screaming after readmission to the facility with a femur fracture. The IDON acknowledged the pain level assessment by the licensed nurses did not reflect the need for a pain medication if the pain level was 0. The IDON confirmed, the IDT missed to review and reasses the need for Resident 4's pain medication regimen. During an interview with certified nursing assistant E (CNA E ) on 12/19/19 at 8:38 a.m., she stated Resident 4 would scream when "lightly" being touched on her hands, but had no pain on her lower extremities. During an interview with licensed vocational nurse D (LVN D) on 12/19/19 at 8:45 a.m., she confirmed she would give Resident 4 a Norco even without pain and she would put 0. A review of the faclity's policy, "Pain Assessment and Management", dated 10/2010, indicated pain management was a multidisciplinary care process that includes modifying approches as necessary. The policy FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 31 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 if pain symptoms have resolved or there was no longer an indication for pain medication, the multidiciplinary team and physician should try to discontinue or taper analgesic medications to the extent possible.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 01/18/2020 §483.45(e) Psychotropic Drugs. §483.45(c)(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 Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(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; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 32 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to adequately monitor the side effects of psychotropic drugs for two of six residents (Residents 9 and 109). This failure had the potential to result in staff not identifying adverse consequences in residents. Findings: 1. Review of Resident 9's clinical record indicated he was admitted to the facility on 10/2/19 with diagnoses including dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning). Review of Resident 9's physician orders indicated he had the following orders, all dated 10/2/19: a. Buspirone hydrochloride (medication used to treat anxiety) tablet 7.5 milligrams (mg, unit of measurement) give one tablet by mouth two times a day; b. Quetiapine fumarate (medication used to treat mood disorders) tablet, give 25 mg by mouth one time a day; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 33 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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. Quetiapine fumarate tablet, give 50 mg by mouth at bedtime. There was no documentation that indicated side effects or adverse consequences of buspirone and quetiapine were being monitored for Resident 9. During an interview on 12/19/19 at 11:26 a.m., the interim director of nursing (IDON) stated side effects used to be monitored and documented in the medication administration record (MAR). During an interview on 12/19/19 at 11:54 a.m., the director of staff development (DSD) stated staff used to complete the abnormal involuntary movement scale (used to detect presence and severity of involuntary movements), but did not anymore. She was unable to find documentation of adequate monitoring of side effects. 2. Review of Resident 109's clinical record indicated she was admitted to the facility on 11/26/19 with diagnoses including fracture of the right lower leg and chronic kidney disease. Review of Resident 109's physician orders indicated an order, dated 11/26/19 remeron (medication used to treat depression) give 15 mg by mouth every day. There was no documentation that indicated side effects of remeron were being monitored for Resident 109. During an interview on 12/17/19 at 3:12 p.m., the IDON stated there was no documentation that indicated side effects were being monitored, except in the care plan. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 34 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd Los Gatos, CA 95032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the facility's policy, "Limitations of Psychoactive Drugs," revised 1/18/18, indicated facility staff will monitor psychotropic medication use and note adverse effects or changes in resident behavior and report to provider. Review of the facility's policy, "Antipsychotic Medication Use," revised 12/2016, indicated nursing staff shall monitor for and report side effects and adverse consequences of antipsychotic medications to the attending physician. Lexi-comp online (an online drug information resource) indicated abnormal involuntary movements or parkinsonian signs and tardive dyskinesia should be monitored.

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

F761 01/18/2020 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 35 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 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 document review, the facility failed to store medications in a safe manner when nursing staff left the medication refrigerator unlocked. This failure had the potential to allow residents and unauthorized staff to access medications. Findings: During an observation on 12/17/19 at 3:33 p.m., the medication refrigerator in Station 2 was left unlocked. During a concurrent interview, the interim director of nursing (IDON) stated she thought it should be locked but she was not sure. Review of the facility's undated policy, "Medication Storage," indicated medications will be stored in a safe, secure, and orderly manner, and accessible only to those authorized to administer medications in accordance with Federal and State laws.

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

F880 01/18/2020 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 36 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd Los Gatos, CA 95032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 37 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure infection prevention practices were followed for five of 51 residents ( Residents 16, 32, 110, 111, and 108 ) when: 1. For Residents 16 and 32, a staff did not perform proper glove technique during wound treatment. 2. For Residents 110, 111, and 108 a staff did not perform hand hygiene during dining observation. These deficient practices had the potential to spread infection. Findings: 1. During a wound treatment observation on 12/18/19 at 10:50 a.m., registered nurse I (RN I ) performed a wound treatment to Resident 16's left heel. RN I applied gloves, cleaned the wound with a saline bullet, wiped with a gauze FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 38 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 to dry and with the same gloves, applied the medi-honey (medical grade honey) gel. RN I continued to cover the wound, applied the boot and touched a pillow and covered the resident with a sheet with the same gloves. During a wound treatment observation on 12/18/19 at 11:10 a.m., RN I performed a wound treatment to Resident 32's coccyx area. RN I applied gloves, raised the bed and removed the sheet. With the same gloves, RN I cleaned the wound with saline, dried the wound, and applied santyl (debriding ointment). RN I continued to cover the wound, pulled Resident 32's pajamas, positioned the pillows, and handled bed control to lower the bed with the same gloves. During an interview with RN I on 12/18/19 at 1:20 p.m., he confirmed he should change gloves after cleaning a dirty wound, then wash his hands and put on new gloves to apply clean dressings and medication. RN I stated dirty gloves should not be used to touch bed controls, bed linens, pillows, and boot. 2. During a dining observation on 12/16/19 at 12:35 p.m., certified nursing assistant F (CNA F) was observed passing meal trays. CNA F went to Resident 110's room, repositioned the table, opened a can of soda and went out of room. CNA F proceeded to deliver a meal tray to Resident 111. CNA F was observed opening the soup cover for Resident 111, and went out of room. CNA F then proceeded to deliver a meal tray to Resident 108. CNA F was observed repositioning Resident 108's table, opened the carton of milk. During these observations, CNA F did not perform hand hygiene in between passing the trays to Residents 110, 111, and 108. During a follow-up interview with CNA F on 12/16/19 at 12:55 p.m., he confirmed he forgot FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 39 of 40 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: _______________ 555547 (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES OF LOS GATOS 800 Blossom Hill Rd 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 to wash his hands or use the hand sanitizer located in the room. During an interview with the interim director of nursing (IDON) on 12/16/19 at 2:21 p.m., the IDON stated CNA F should perform hand hygiene when passing meal trays and touching tables in between residents. A review of the facility's undated policy, "Infection Control, Procedure for Wound Care/Change of Dressing", indicated as follows: remove old dressings, remove gloves, wash hands, apply clean gloves, cleanse wound, observe the wound for size, remove gloves, wash hands, apply any medication ordered, remove gloves, wash hands and return resident to safe, comfortable position. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U2711 Facility ID: CA070000778 If continuation sheet 40 of 40