Health inspection·January 23, 2020

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow facility policy related to accountability and documentation of controlled substances (drugs with high potential for abuse and addiction) for four out of six sampled residents when: 1. For Resident 21, quantity of a controlled substance received from the pharmacy does not match what was documented. 2. For Resident 29, a controlled substance was delivered by a licensed nurse to a general acute hospital without obtaining permission to leave and missing documentation related to physician's order. 3. For Resident 1, a controlled substance was not properly documented. 4. For Resident 30, 4.6ml (milliliters, a unit of measurement) of a controlled substance was not accounted for and not reported immediately to responsible supervisor. These failures had a potential for diversion of highly controlled substances. Findings: 1. For Resident 21, quantity of a controlled substance received from the pharmacy does not match what was documented. During a review of Resident 21's admission Record, dated 1/22/2020, indicated Resident 21 was admitted on [DATE] with the following diagnoses including congenital (occurring before birth) malformation of musculoskeletal system (affecting the body's bones and muscle), exotropia (is a form of eye misalignment in which one or both of the eyes turn outward) and chronic respiratory failure (is a condition that results in the inability to effectively exchange carbon dioxide and oxygen). During an observation with licensed vocational nurse G (LVN G) on 1/22/2020 at 11:18 a.m., indicated on Resident 21's Diazepam's (a schedule IV-controlled substance used for anxiety) pharmacy label was a quantity of 30. LVN G confirmed pharmacy label indicated 30 which was the amount pharmacy dispensed. During a record review on 1/22/2020 at 11:20 a.m., Resident 21's-controlled drug record, indicated, Diazepam 5mg (milligram, a unit of measurement) /5ml (milliliter, a unit of measurement) give 2mg (2ml) via GT (gastrostomy tube) twice a day as needed for muscle spasm amount received 31 ml. It further indicated that on 12/14/19 at 11:19 a.m., 2 ml of Diazepam was administered to Resident 21 and 29 ml was left on the bottle. During an interview on 1/22/2020 at 11:41 a.m., with the director of nursing (DON), the DON stated facility staff should follow the quantity dispensed by the pharmacy to match controlled drug record documentation. The DON also stated she was not aware about this discrepancy until today. 2. For Resident 29, a controlled substance was delivered by a licensed nurse to a general acute hospital without obtaining permission to leave and missing documentation related to physician's order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555204 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA Saratoga Pediatric Subacute 13425 Sousa Lane Saratoga, CA 95070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 29's admission Record, dated 1/22/2020, indicated Resident 29 was admitted on [DATE] with following diagnoses including bronchopulmonary dysplasia (is a form of chronic lung disease that affects newborns), hypertension (high blood pressure), epilepsy (a disorder in which nerve cell activity in the brain is distributed, causing seizures) and spastic quadriplegic cerebral palsy (difficulty in controlling movements in the arms and the legs). Residents Affected - Few During an interview on 1/22/2020 at 2:56 p.m., with the minimum data set nurse (MDSN), the MDSN stated Resident 29 was hospitalized [DATE] and returned on 1/8/2020. During an interview on 1/22/2020 at 3:45 p.m. with registered nurse H (RN H), RN H stated Resident 29's Clobazam (a schedule IV-controlled substance used to treat seizures) was delivered by another licensed nurse to a general acute care hospital on 1/5/2020. RN H stated that there was no documentation in Resident 29's health records related to a physician's order to send medication to general acute. RN H also stated she did not notify the DON related to Resident 29's-controlled medication being sent to a general acute care hospital. During an interview on 1/22/2020 at 3:54 p.m., with the DON, the DON stated she was not notified a licensed nurse left the facility and delivered controlled medication to a general acute care hospital for Resident 29. During an interview on 1/23/2020 at 12:01 p.m. with the DON, he DON stated license nurses are not allowed to leave the facility to transfer medication out to a general acute hospital without the permission of the DON or administrator (ADMIN). The DON also stated she was not able to find documentation in Resident 29's health records related to physician's order to send medication out to a general acute care hospital. During an interview on 1/23/2020 at 2:08 p.m. with the ADM, the ADM stated he did not give permission to license nurse to leave premise and deliver medication to a general acute care hospital. During a review of the facility's policy, dated 4/25/15, Controlled Substances, indicated remaining controlled substances not authorized by the physician to go with the patient at the time of discharge will not be surrender to any other person for any reason. During a review of the facility's policy, dated 4/18, Employee Handbook, indicated failing to obtain permission to leave work for any reason during normal working hours is a prohibited conduct. 3. For Resident 1, a controlled substance was not properly documented. During a review of Resident 1's admission Record, dated 1/22/2020, indicated Resident 1 was admitted on [DATE] with following diagnoses including spina bifida (a birth defect in which there is incomplete closing of the spine and membranes around the spinal cord during early development in pregnancy), epilepsy, hydrocephalus (is the buildup of fluid in the cavities deep within the brain) and hypotension (low blood pressure). During a review of Resident 1's Controlled Drug Record, received on 1/3/2020, indicated Clobazam 10 mg tablet dose number 60 has no date and time of administration. During an interview on 1/23/2020 at 12:28 p.m. with the DON, the DON confirmed Resident 1's-controlled drug record for Clobazepam has missing documentations (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555204 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA Saratoga Pediatric Subacute 13425 Sousa Lane Saratoga, CA 95070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy, dated 4/25/15, Controlled Substances, indicated separate records will be maintained on all Schedule II, III, and IV drugs. This will be in the form of a declining inventory record. Such records will be accurately maintained and will include: 1. The name of the patient Residents Affected - Few 2. The name of the prescriber 3. The prescription number 4. The drug name and form of the medication 5. The strength and dose administration 6. The date of administration 7. The amount remaining 8. The signature of the person administering the drug 4. For Resident 30, 4.6ml (milliliters, a unit of measurement) of a controlled substance was not accounted for and not reported immediately to responsible supervisor. During a review of Resident 30's admission Record, dated 1/22/2020, indicated Resident 30 was admitted on [DATE] with following diagnoses including congenital malformation of brain (a group of brain defects or disorders that develop in the womb and are present at birth), hearing loss, congenital hypertonia (is characterized as contractures or stiffness of all voluntary muscles usually present from birth) and convulsion (is a medical condition where body muscles contract and relax rapidly and repeatedly, resulting in uncontrolled actions of the body). During a review of Resident 30's Controlled Drug Record, indicated on 1/19/2020 at 11:00 p.m., 1.8 ml of Diazepam (a schedule IV-controlled substance used to treat anxiety, muscle spasms and seizures) was documented, and 364.8 ml was remaining in the bottle. It also indicated on 1/19/2020 at 11:00 p.m., received amount was 360 ml and it was signed by two licensed nurses. During an interview on 1/23/2020 at 12:14 p.m., with the DON, the DON confirmed the discrepancy of 4.8 ml for Resident 30's-controlled substance above. The DON stated she was not notified about the discrepancy and there was no documentation in Resident 30's progress notes that the facility staff notified the consultant pharmacist about above discrepancy. During a review of the facility's policy, dated 4/25/15, Controlled Substances, indicated any discrepancy in the count is to be reported in writing immediately to the responsible supervisor and a signed entry is recorded on the page where the discrepancy is found. It also indicated that the consultant pharmacist will be notified immediately of any discrepancy of controlled medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555204 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA Saratoga Pediatric Subacute 13425 Sousa Lane Saratoga, CA 95070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had 8% medication error rate when two medication errors out of 25 opportunities were observed during medication pass. This failure resulted in Resident 30 not getting his medications as ordered by the physician. Residents Affected - Few Findings: 1. During medication pass observation on 1/21/2020 at 4:56 p.m. with Registered Nurse B (RN B), RN B did not give the half remaining portion of crushed glycopyrrolate (medication used to reduce drooling in children ages 3 to 16 who have certain medical conditions, such as cerebral palsy) in the medication cup. During an interview on 1/21/2020 at 6:00 p.m. with RN B, he acknowledged the above observation. RN B further stated that he forgot to give the half remaining portion of the medication to complete the dose as ordered by the physician. During a review of the physician order, dated 12/5/2019, indicated Resident 30 was to receive glycopyrrolate half tablet of 1 milligram (mg, a unit of measurement) 0.5 mg. via gastrostomy tube (GT, a tube inserted through the abdomen into the stomach) every eight hours for secretion reduction daily at 1:00 a.m., 9:00 a.m., 5:00 p.m. 2. During medication pass observation on 1/21/2020 at 5:07 p.m., RN B administered three milliliters (ml, a unit of measurement for volume) of Ferrous sulfate (iron Medication) 75 mg (equivalent to 15 mg. Iron) per one ml. from house supply bottle via GT. During a review of the physician order, dated 1/8/2020, indicated Resident 30 was to receive ferrous sulfate drops 75 mg. (equivalent 15 mg. iron/1 ml.) give 225 mg- iron 45 mg(3ml) via GT daily at 5:00 p.m. During a concurrent interview and record review with the director of nursing (DON) on 1/22/2020 at 10:12 a.m., the DON stated ferrous sulfate house supply that was given by RN B to Resident 30 on 1/21/2020 had wrong contents and the DON further stated that Resident 30 has his own supply from the pharmacy with the right components as ordered by the physician. Review of the facility's undated policy, Medication Administration, indicated All iron and calcium doses will be ordered as elemental, e.g., elemental iron and elemental calcium Orders will specify the amount of the elemental components. Review of the facility's undated policy and procedure, Medication Administration-Physician Order, indicated the five rights will be followed when administering medication .Right patient, right medication, right dose, right route, and right frequency . To assure administration accuracy the nurse will cross check the following reference points: Physician's Order- I-MAR, I-MAR- Rx label, Label on drug container- Physician's Order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555204 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA Saratoga Pediatric Subacute 13425 Sousa Lane Saratoga, CA 95070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 2. During a breathing treatment observation on 1/21/2020 at 5:41 p.m. with respiratory therapist C (RT C), RT C had a medication room key to get Resident 4's respiratory medications inside the medication room without the facility licensed nurse present. During an interview on 1/21/2020 at 6:04 p.m. with RT C, RT C acknowledged the above observation. RT C further stated she had her own key to enter the medication room without the facility licensed staff present. During a breathing treatment observation on 1/21/2020 at 4:40 p.m. with RT F, RT F had a medication room key to get Resident 12' s respiratory medications inside the medication room without the facility licensed nurse present. During an interview on 1/21/2020 at 5:31 p.m. with RT F, RT F confirmed the above observation. RT F stated he had his own key to go inside the medication room without facility licensed staff present. During an interview on 1/23/2020 at 12:43 p.m. with the administrator (ADM), he stated only licensed nurses should have the key to the medication room. He further stated respiratory therapists should not have keys to the medication room and could not access the medication room without the presence of a licensed nurse. Review of the facility's undated policy and procedure, Medication Administration-Physician Order, indicated only licensed personnel are assigned responsibility for preparing, administering, and recording of medications or have access to the drug storage areas . (Cart and Medication room). Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored and labeled appropriately when: 1. Several medications were expired in the medication room; 2. Unauthorized personnel had access to the medication room; 3. Undated liquid bottles of medications. These failures had the potential for drug diversion and residents to receive expired, contaminated, or deteriorated medications and biologicals. Findings: 1. During a medication room observation on 1/21/2020 at 9:26 a.m. with the Director of Staff Development (DSD), the following were observed: 1a. 11 heparin lock syringe (blood thinner to prevents clots) 50 units/5 ml (units, milliliters, unit of measurement) expired on 10/31/19; 1b. 14 sodium chloride 3% (medication, that can be used to dilute other medications through a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555204 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA Saratoga Pediatric Subacute 13425 Sousa Lane Saratoga, CA 95070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 nebulizer) vials expired on December 2019. Level of Harm - Minimal harm or potential for actual harm 1c. one opened and one unopened pack of ipratropium bromide 0.02% (medication used to prevent and control symptoms of wheezing and shortness of breath caused by ongoing lung diseases). Residents Affected - Few The DSD confirmed the above observation and stated regular checking of the medroom was night shift licensed nurse's responsibility. Review of the facility's undated policy, Storage of Medications, indicated expired medications shall not be kept. 3. Undated liquid bottles of medications During an observation and interview on 1/22/2020 at 11:18 a.m. with licensed vocational nurse G (LVN G), LVN G confirmed the following bottles were opened and had no date when opened: 1. Poly Vi Sol (multivitamin supplement) 2. Poly Vi Sol with Iron 3. Loratadine (used to treat allergy symptoms and hives) oral solution 4. Liquid Pain Relief 5. Iron Supplement 6. Pedialyte (advanced hydration rehydration drink) During an observation and interview on 1/22/2020 at 11:46 a.m. with registered nurse K (RN K), RN K confirmed the following bottles were opened and had no date when opened: 1. Loratadine oral solution 2. Allergy relief 3. Liquid pain relief During an interview on 1/22/2020 at 11:58 a.m. with RN K, RN K stated all liquid bottles of medication should be dated when opened. During a review of the facility's undated policy, Medication Administration, indicated when using a new liquid medication for the first time, the bottle will be marked with the date opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555204 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA Saratoga Pediatric Subacute 13425 Sousa Lane Saratoga, CA 95070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1a. During an observation on 1/21/2020 at 1:20 p.m., HK E was wearing gloves in the hallway, entered room [ROOM NUMBER] then exited the room with the same gloves on then proceeded to enter room [ROOM NUMBER] without changing or removing gloves. HK E exited rooms 14, 15, 17, 18 and 19 with the same gloves, proceeded to collect garbage from rooms 14, 15, 17, 18, 19 without changing gloves and without performing hand hygiene. Residents Affected - Some During a concurrent observation and interview on 1/21/2020 at 1:26 p.m. with HK E, HK E confirmed the above observations and stated they [house keeping] are not required to change gloves when they go room to room to collect garbage and they can wear gloves in the hallway. 2. During an initial tour observation on 1/21/2020 at 7:53 a.m., Resident 4's oxygen nasal cannula tubing was touching the bedside table. During a concurrent observation and interview on 1/21/2020 at 7:54 a.m. with licensed vocational G (LVN G), she confirmed the above observation. During an observation on 1/21/2020 at 7:58 a.m., Resident 4's oxygen connector was touching the side rail. During a concurrent observation and interview on 1/21/2020 at 7:59 a.m. with LVN G, she confirmed the above observation. 3. Not performing handwashing between removing and donning gloves. During an observation on 1/22/2020 at 4:12 p.m. with licensed vocational nurse L (LVN L), LVN L pulled the curtain, removed gloves, placed used gloves on Resident 10's bedside table and donned new gloves without performing hand hygiene. During an interview on 1/22/2020 at 4:18 p.m., LVN L confirmed she did not perform hand hygiene between removing and donning gloves. During an interview on 1/23/2020 at 12:50 p.m. with the director of nursing (DON), the DON stated facility staff should perform hand hygiene between removing and donning gloves. During a review of the facility's undated policy, Hand Hygiene Program & Procedure, indicated 5. Hand hygiene shall be done at the following times: k after taking off gloves sterile or unsterile 4. During an observation on 1/21/2020 at 8:06 a.m., the medication cart side garbage bag next to Resident 4's bedside table was overflowing. During a concurrent observation and interview on 1/21/2020 at 7:59 a.m. with LVN G, she confirmed the above observation. She further stated the garbage bag should not be overflowing due to infection control issues. 5. During an observation on 1/21/2020 at 9:18 a.m., CNA M was carrying used linens after providing activities of daily living (ADL's) care to Resident 28 with gloves on and she disposed the linens inside the dirty yellow bin inside the room then touched the side rail of Resident 28 without changing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555204 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA Saratoga Pediatric Subacute 13425 Sousa Lane Saratoga, CA 95070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some gloves and without performing hand hygiene. CNA M was wearing the same gloves when she picked up a used paper towel on Resident 28's bedside, then proceeded to the bathroom touching the bathroom handle with the same gloves and without performing hand hygiene. During a concurrent observation and interview with LVN G, she acknowledged the above observation. She further stated CNA M should have changed gloves and performed hand hygiene in every procedure. 6. During an observation on 1/21/2020 at 9:04 a.m., Resident 20's ambu bag was exposed and was not inside the plastic bag. During an observation on 1/21/2020 at 8:15 a.m., Resident 5's ambu bag and mask was exposed and was not inside the plastic bag. During a concurrent observation and interview on 1/21/2020 at 8:38 a.m. with the director of respiratory therapy (DRT), he acknowledged the above observations. The DRT stated all ambu bags, masks and other oxygen delivery devices should be kept inside a plastic bag. He further stated he was checking and putting all the ambu bags and masks inside a plastic bag for each resident in the facility. Review of the facility's policy and procedure, Equipment Cleaning Policy, dated February 20, 2018, indicated the Respiratory Care Department participates in the hospital-wide infection control program, following the guidelines and procedures detailed in the approved hospital infection Control Manual . Oxygen delivery devices such as simple mask, cannulas, oxygen tubing, nebulizers and etc. These items will be stored in equipment containers. Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were followed when: 1. Housekeeper (HK E) did not change gloves and did not perform hand hygiene; 2. Resident 4's oxygen nasal cannula tubing (a device used to deliver supplemental oxygen or airflow) was touching the bedside table; 3. Resident 4's oxygen connector was exposed and touching the side rail; 4. Medication cart garbage next to the Resident 4's bedside table was over flowing; 5. Certified nursing assistant M (CNA M) did not change gloves and did not perform hand hygiene; 6. Ambu bags were not stored inside the equipment containers. These failures had the potential to spread infection in the facility. 1. During an observation on 1/21/2020 at 1:12 p.m. HK E exited room [ROOM NUMBER] with gloves then proceeded to room [ROOM NUMBER] without changing or removing gloves. HK E exited room [ROOM NUMBER] with the same gloves, proceeded to collect the medcart garbage and entered room [ROOM NUMBER] without changing gloves and without performing hand hygiene. HK E confirmed the above observation and stated, they [house keeping] are not required to change gloves when they go room to room to collect garbage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555204 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA Saratoga Pediatric Subacute 13425 Sousa Lane Saratoga, CA 95070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview with the Pediatric Services Coordinator/Infection Preventionist (PSC/IP) on 1/23/2020 at 2:14 p.m., the PSC/IP stated staff should remove gloves and do hand hygiene every time they enter the room. Review of the facility's policy, Hand Hygiene Program and Procedure, indicated hand hygiene should be done after handling contaminated items and gloves should not be worn in the hallway. Event ID: Facility ID: 555204 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555204 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA Saratoga Pediatric Subacute 13425 Sousa Lane Saratoga, CA 95070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to ensure aerosol disinfectant was stored properly when the chemical disinfectant was found at the bed side of Resident 4. This failure had the potential for Resident 4 to access the hazardous chemical and jeopardize his health and safety. Findings: During breathing treatment observation on 1/21/2020 at 5:41 p.m. with respiratory therapist C (RT, a specialized healthcare practitioner trained in pulmonary medicine in order to work therapeutically with people suffering from pulmonary disease), a one 19 oz. disinfectant aerosol bottle was found at the bedside table next to the breathing treatment machine and suction machine for Resident 4. During a concurrent observation and interview with RT C on 1/21/2020 at 5:51 p.m., RT C acknowledged the above observation. She further stated Resident 4 could easily grab the aerosol bottle and it should not be kept at the bedside for Resident 4's safety. During a concurrent observation and interview with registered nurse B (RN B) on 1/21/2020 at 5:54 p.m., he acknowledged the above observation. He further stated the aerosol bottle should not be kept at the bedside for Resident 4's safety. During a concurrent observation and interview with certified nursing assistant D (CNA D) on 1/21/2020 at 5:55 p.m., she acknowledged the above observation. CNA D further stated she forgot to put away the aerosol bottle after she used it. Review of the facility's undated policy, Housekeeping Guidelines indicated all staff should always keep cleaning chemicals out of reach of children . No cleaning chemicals should be stored or left on residents/patients . make sure all cleaning chemicals are always stored and locked in the housekeeping closet/cart when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 11 of 11