Health inspection·July 23, 2024

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, interview, and record review, the facility failed to follow their Bed/Side Rails policy for 20 of 22 residents (1, 2, 3, 4, 5, 6, 9, 11, 14, 16, 18, 23, 24, 25, 27, 181, 182, 184, 330, and 331) when they did not attempt alternative measures prior to applying bed side rails. This failure had the potential to place the residents at risk of entrapment and serious injury. Findings: During an observation in Resident 11's room on 7/15/24, at 10:19 a.m., Resident 11 was in bed with side rails up. Review of Resident 11's physician order, dated 2/7/23, indicated she had an order for Upper Side Rails. Review of Resident 11's Postural Support/Developmental Safety Device Rationale and Consent, dated 12/19/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 1's room on 7/15/24, at 10:20 a.m., Resident 1 was in bed with left side rail up. Review of Resident 1's physician order, dated 7/12/23, indicated she had an order for Left Side Rail. Review of Resident 1's Postural Support/Developmental Safety Device Rationale and Consent, dated 1/9/23, indicated alternative measures were not attempted prior to the use of side rail. During an observation in Resident 2's room on 7/15/24, at 10:22 a.m., Resident 2 was in bed with side rails up. Review of Resident 2's physician order, dated 11/29/21, indicated he had an order for Side Rails. Review of Resident 2's Postural Support/Developmental Safety Device Rationale and Consent, dated 12/20/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 181's room on 7/15/24, at 10:25 a.m., Resident 181 was in bed with side rails up. Review of Resident 181's physician order, dated 2/16/24, indicated he had an order for Full Side Rails. Review of Resident 181's Postural Support/Developmental Safety Device Rationale and Consent, dated 3/22/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 25's room on 7/15/24, at 10:27 a.m., Resident 25 was in bed with side rails up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 2 of 12 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 07/23/2024 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 0700 Review of Resident 25's physician order, dated 10/18//23, indicated she had an order for Upper Side Rails. Level of Harm - Minimal harm or potential for actual harm Review of Resident 25's Postural Support/Developmental Safety Device Rationale and Consent, dated 1/17/24, indicated alternative measures were not attempted prior to the use of side rails. Residents Affected - Many During an observation in Resident 16's room on 7/15/24, at 10:28 a.m., Resident 16 was in bed with side rails up. Review of Resident 16's physician order, dated 2/15/23, indicated she had an order for Upper Side Rails. Review of Resident 16's Postural Support/Developmental Safety Device Rationale and Consent, dated 3/27/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 5's room on 7/15/24, at 10:29 a.m., Resident 5 was in bed with side rails up. Review of Resident 5's physician order, dated 2/15/23, indicated she had an order for Left Right Side Rails. Review of Resident 5's Postural Support/Developmental Safety Device Rationale and Consent, dated 4/9/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 182's room on 7/15/24, at 11:19 a.m., Resident 182 was in bed with side rails up. Review of Resident 182's physician order, dated 11/10/23, indicated he had an order for Full Side Rails. Review of Resident 182's Postural Support/Developmental Safety Device Rationale and Consent, dated 11/7/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 3's room on 7/15/24, at 11:31 a.m., Resident 3 was in bed with side rails up. Review of Resident 3's physician order, dated 5/23/24, indicated she had an order for All Side Rails. Review of Resident 3's Postural Support/Developmental Safety Device Rationale and Consent, dated 5/17/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 330's room on 7/15/24, at 12:11 p.m., Resident 330 was in bed with bilateral (both sides) upper side rails and one lower side rail up. Review of Resident 330's physician order, dated 12/12/23, indicated he had an order for Upper Side Rails. Review of Resident 330's Postural Support/Developmental Safety Device Rationale and Consent, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 3 of 12 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 07/23/2024 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 0700 12/12/23, indicated alternative measures were not attempted prior to the use of side rails. Level of Harm - Minimal harm or potential for actual harm During an observation in Resident 4's room on 7/15/24, at 12:11 p.m., Resident 4 was in bed with one upper and one lower side rails up. Residents Affected - Many Review of Resident 4's physician order, dated 2/17/23, indicated he had an order for Upper Side Rails. Review of Resident 4's Postural Support/Developmental Safety Device Rationale and Consent, dated 12/14/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 24's room on 7/15/24, at 12:12 p.m., Resident 24 was in bed with bilateral upper and lower side rails up. Review of Resident 24's physician order, dated 2/27/24, indicated he had an order for Upper Side Rails. Review of Resident 24's Postural Support/Developmental Safety Device Rationale and Consent, dated 2/28/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 27's room on 7/15/24, at 12:12 p.m., Resident 27 was in bed with bilateral upper side rails and one lower side rail up. Review of Resident 27's physician order, dated 1/30/24, indicated he had an order for Full Side Rails. Review of Resident 27's Postural Support/Developmental Safety Device Rationale and Consent, dated 3/22/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 9's room on 7/15/24, at 12:13 p.m., Resident 9 was in bed with bilateral upper side rails up. Review of Resident 9's physician order, dated 11/14/23, indicated she had an order for Side Rails. Review of Resident 9's Postural Support/Developmental Safety Device Rationale and Consent, dated 5/23/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 14's room on 7/15/24, at 12:27 p.m., Resident 14 was in bed with bilateral upper and lower side rails up. Review of Resident 14's physician order, dated 2/13/23, indicated she had an order for Full Side Rails. Review of Resident 14's Postural Support/Developmental Safety Device Rationale and Consent, dated 5/23/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 6's room on 7/16/24, at 8:15 a.m., Resident 6 was in bed with bilateral upper side rails up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 4 of 12 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 07/23/2024 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 0700 Review of Resident 6's physician order, dated 10/11/19, indicated she had an order for Side Rails. Level of Harm - Minimal harm or potential for actual harm Review of Resident 6's Postural Support/Developmental Safety Device Rationale and Consent, dated 5/17/24, indicated alternative measures were not attempted prior to the use of side rails. Residents Affected - Many During an observation in Resident 331's room on 7/16/24, at 8:33 a.m., Resident 331 was in bed with bilateral upper and lower side rails up. Review of Resident 331's physician orders indicated there was no order for the use of side rails. Review of Resident 331's Postural Support/Developmental Safety Device Rationale and Consent, dated 8/25/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 18's room on 7/16/24, at 8:33 a.m., Resident 18 was in bed with bilateral upper and lower side rails up. Review of Resident 18's physician order, dated 2/15/23, indicated he had an order for Upper and Lower Side Rails. Review of Resident 18's Postural Support/Developmental Safety Device Rationale and Consent, dated 12/14/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 184's room on 7/17/24, at 11:25 a.m., Resident 184 was in bed with side rails up. Review of Resident 184's physician order, dated 7/16/24, indicated he had an order for Upper Side Rails. Review of Resident 184's Postural Support/Developmental Safety Device Rationale and Consent, dated 7/8/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 23's room on 7/17/24, at 11:32 a.m., Resident 23 was in bed with side rails up. Review of Resident 23's physician order, dated 7/16/24, indicated she had an order for Upper Side Rails. Review of Resident 23's Postural Support/Developmental Safety Device Rationale and Consent, dated 7/11/24, indicated alternative measures were not attempted prior to the use of side rails. During an interview with the rehabilitation supervisor (RS) on 7/22/24, at 11:33 a.m., she stated the alternative measures such as frequent visual check for safety, pillow/wedged cushions, or frequent repositioning, etc. would be attempted only if the responsible party (the party responsible to making health care decisions when the principal party is unable to make health care decisions for him or herself) of the resident refused to give the consent for side rail. Otherwise, the side rail would be used. The RS acknowledged that the alternative measures should be attempted prior to the use of side rail. During an interview with the director of nursing (DON) on 7/22/24, at 11:36 a.m., she confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 5 of 12 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 07/23/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm alternative measures were not attempted for Residents 1, 2, 3, 4, 5, 6, 9, 11, 14, 16, 18, 23, 24, 25, 27, 181, 182, 184, 330, and 331 prior to the use of side rail. Review of the facility's undated policy, Bed/Side Rails, indicated, . 4. Appropriate alternative interventions are to be utilized prior to using bed/side rails . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 6 of 12 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 07/23/2024 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 Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure the nursing staff administered a medication accurately according to the manufacturer's specifications for one of 12 sampled residents (Resident 331), when Resident 331's Lansoprazole (drug used to reduce stomach acid) Oral Disintegrating Tablet (ODT, fast-melting tablet that dissolves quickly in saliva/water) 30 milligrams (mg, unit of mass measurement) was crushed before administration, contrary to the manufacturer's guidelines. This failure had the potential to reduce medication efficacy for Resident 331. Findings: During an observation of a medication administration on 7/15/24 at 8:28 a.m., Licensed Vocational Nurse A (LVN A) crushed a tablet of lansoprazole ODT 30 mg then mixed it with water prior to administering the mixture to Resident 331. During an interview with LVN A on 7/15/24 at 8:38 a.m., she stated she crushed all of Resident 331's medications according to Resident 331's physician's orders. During a concurrent interview and record review on 7/15/24 at 2:32 p.m. with LVN A, review of the facility's Nursing drug Handbook, 2024 edition, page 1421, with LVN A indicated lansoprazole ODT should not be broken. LVN A acknowledged and stated she should not have crushed the lansoprazole tablet . During a concurrent interview and record review with Registered Nurse B (RN B) on 7/17/24 at 8:59 a.m., he stated he administered the lansoprazole ODT tablet to Resident 331 earlier this morning by crushing it and mixing it in water before administration. RN B reviewed the above-mentioned Nursing Drug Handbook, and stated he forgot that it is not to be crushed. A review of the pharmacy label on the bag containing Resident 331's lansoprazole ODT tablets indicated, Do not chew or crush. Review of Resident 331's physician's order, dated 1/12/24, indicated to give lansoprazole 30 mg via G-tube (a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) one time a day for gastritis (inflammation of the lining of the stomach). Review of Resident 331's July 2024 Medication Administration Record indicated LVN A administered the lansoprazole ODT 30 mg to the resident four times on: 7/3/24, 7/4/24, 7/12/24, and 7/15/24; and, RN B administered it four times on: 7/9/24, 7/10/24, 7/11/24, and 7/17/24. Review of the facility's policy and procedure titled, Medication Administration, dated 10/2023, indicated, Each nurse should comply with the recommended medication administration guidelines and specific hospital policies developed to foster safety and efficacy in the current published references available on the nursing units. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 7 of 12 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 07/23/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a multi-dose medication was labeled with an open date after opening, and not stored beyond its discarding date. This failure had the potential for residents to receive expired, contaminated, or deteriorated medication. Finding: During an observation and record review with Registered Nurse B (RN B) on [DATE] at 10:12 a.m., an open 10 milliliter (mL) multi-dose vial of lorazepam (a controlled medication to treat seizures and agitation) 2 milligrams/mL was identified in the medication refrigerator without an open date on the vial. RN B reviewed the Controlled Drug Record and stated the lorazepam vial was opened on [DATE] (4 months ago). He acknowledged the vial should have been labeled with an open date. During a follow-up interview on [DATE] at 2:08 p.m., RN B stated he checked with the pharmacy and was told the lorazepam vial should be discarded 28 days after it was punctured. During a telephone interview with the Consultant Pharmacist (CP) on [DATE] at 2:50 p.m., she stated multi-dose vials should be discarded 28 days after opening to minimize cross contamination (a process by which harmful bacteria are unintentionally transferred from one object to another). A review of the facility's Multiple dose Vial policy and procedure, dated 11/2023, indicated, all multi-dose vials with preservatives shall be dated and initialed when opened, and discarded within 28 days unless a shorter expiration date is indicated on the label. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 8 of 12 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 07/23/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when: Residents Affected - Some 1. Food was kept beyond their open and expiration dates, 2. Temperature logs for two refrigeration units had missing entries, 3. Five opened spice containers were without expiration dates, 4. Three cutting boards had deep cut marks on their surface, 5. Five red onions and four yellow onions were moldy, six potatoes were soft and wrinkled, and 6. A fan had dark particles on its fan blades and grills. These failures had the potential to cause food-borne illness for residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview with the dietary supervisor (DS) on 7/15/24 at 8:40 a.m., the DS confirmed the following food items located in active use areas of the kitchen were expired: potato salad, left over beans in an unsealed bag dated 7/8/24, an open bag of broccoli dated 6/24/24. The DS stated left over food are kept 3-5 days the left over beans you have been in a sealed bag. Review of facility's undated policy and procedure (P&P) Food Labeling Policy for Open Food Items, indicated, 3 days open for produce, turkey ham, tuna .deli salad, opened ROP (Reduced Oxygen Packaging) bags and other canned items. Review of facility's P&P Food Safety and Sanitation policy, dated 2013, indicated, Foods with expiration date are used prior to the use by date on the package. Review of The Federal Food and Drug Administration (FDA) Food Code 2022, chapter 3-501.17 (A) (B) (C) (D) indicated the day the original [food] container is opened in the food establishment shall be counted as Day 1 such that, . The date marked shall not exceed a manufacturer's use-by date . mark the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. 2. During a concurrent interview and record review with the DS on 7/15/24 at 8:35 a.m., the DS reviewed the formula refrigerator temperature log located in the hallway, which had missing temperature entries on 7/1/24, 7/5/24, 7/9/24, 7/12/24, 7/13/24, 7/14/24 and 7/15/24; and, the standing refrigerator temperature log located in the kitchen had missing temperature entries on 7/1/24, 7/5/24, 7/11/24, 7/12/24, 7/13/24, and 7/14/24. The DS stated the temperature monitoring of these refrigeration units should have been documented on their respective temperature logs twice daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 9 of 12 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 07/23/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the Daily Refrigerator/Freezer Temperature Log, dated 7/24 indicated, A designated food service employee will record the time, air temperature and their initials (preferably upon arrival) once in the morning and once (preferably just before leaving the facility) in the afternoon. 3. During a concurrent observation and interview with the DA on 7/15/24 at 8:43 a.m., the DA confirmed five spice containers were labeled with open dates, but no expiration or best-by-dates as follows: a. Onion Powder 10/9/23. b. Ground [NAME] Pepper 12/25/23. c. Ground paprika 1/17/23. d. Granulated onion 8/28/23. e. Whole Oregano Leaves 9/7/23, The DA stated the spices will be thrown out. Review of the facility's undated P&P Food Labeling Policy for Open Food items indicated, 90 days for spices, uncooked pasta, rice, nuts . Review of the facility's P&P Food Safety and Sanitation, dated 2013, indicated, Canned and dry foods without expiration dates are used within six months of delivery or according to the manufacturer's guidelines. 4. During a concurrent observation and interview with the DS on 7/15/24 at 8:48 a.m., the DS confirmed the three cutting boards had deep cut marks on their surfaces. The DS stated they should not be used and should be replaced. Review of the The Federal Food and Drug Administration (FDA) Food Code 2022, chapter 4-501.12, indicated surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized . 5. During a concurrent observation and interview with the DS on 7/15/23 at 8:51 a.m., the DS confirmed six potatoes in a bag were soft and wrinkled, and five red onions and four yellow onions in a plastic container were moldy. The DS stated these would be thrown out. Review of the facility's P&P Food Safety and Sanitation, dated 2013, indicated, . food must be clean, wholesome, and free from spoilage. 6. During a concurrent observation and interview with the DS on 7/15/24 at 8:51 a.m., the DS confirmed the electric fan on the floor of the kitchen has dark particles on the fan blades and grills. The DS stated the fan should be cleaned. Review of the The Federal Food and Drug Administration (FDA) Food Code 2022, chapter 4-601.11 (C) indicated, Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 10 of 12 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 07/23/2024 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** Based on observation, interview, and record review, the facility failed to implement infection control practices when the filters of oxygen concentrators were dusty for five of 13 residents (3, 23, 25, 183, and 184). This failure had the potential to spread infection in the facility. Residents Affected - Some Findings: Review of Resident 3's admission Record indicated she was admitted to the facility on [DATE] with a respiratory failure (a condition that makes it difficult to breathe; respiratory failure develops when the lungs cannot get enough oxygen into the blood) diagnosis. Review of Resident 3's physician order, dated 5/10/24, indicated she had an order for oxygen as needed to keep her oxygen saturation (O2 Sat, the amount of oxygen that's circulating in the blood) above 92%. During an observation with respiratory therapist D (RT D) on 7/15/24, at 10:41 a.m., the filter of Resident 3's oxygen concentrator had a layer of dust on it. RT D confirmed the filter of Resident 3's oxygen concentrator was dusty. Review of Resident 23's admission Record indicated she was admitted to the facility on [DATE] with a respiratory failure diagnosis. Review of Resident 23's physician order, dated 7/9/24, indicated she had an order for oxygen as needed to keep her O2 Sat above 92%. During an observation with RT D on 7/15/24, at 10:44 a.m., the filter of Resident 23's oxygen concentrator had a layer of dust on it. RT D confirmed the filter of Resident 23's oxygen concentrator was dusty. Review of Resident 25's admission Record indicated she was admitted to the facility on [DATE] with a respiratory failure diagnosis. Review of Resident 25's physician order, dated 4/24/24, indicated she had an order for oxygen as needed to keep her O2 Sat above 92%. During an observation with RT D on 7/15/24, at 10:49 a.m., the filter of Resident 25's oxygen concentrator had a layer of dust on it. RT D confirmed the filter of Resident 25's oxygen concentrator was dusty. Review of Resident 183's admission Record indicated she was admitted to the facility on [DATE] with dependence on a ventilator (a machine that helps a person breathe or breathes for the person) status (if people are unable to wean off and breathe independently, they become ventilator dependent) diagnosis. Review of Resident 183's physician order, dated 4/24/24, indicated she had an order for oxygen as needed to keep her O2 Sat above 92%. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 11 of 12 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 07/23/2024 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 During an observation with RT D on 7/15/24, at 11 a.m., the filter of Resident 183's oxygen concentrator had a layer of dust on it. RT D confirmed the filter of Resident 183's oxygen concentrator was dusty. Review of Resident 184's admission Record indicated he was admitted to the facility on [DATE] with respiratory failure and dependence on ventilator status diagnoses. Residents Affected - Some Review of Resident 184's physician order, dated 7/1/24, indicated he had an order for oxygen as needed to keep his O2 Sat above 92%. During an observation with RT D on 7/15/24, at 11 a.m., the filter of Resident 184's oxygen concentrator had a layer of dust on it. RT D confirmed the filter of Resident 184's oxygen concentrator was dusty. During a concurrent interview with RT D, she stated the filters of oxygen concentrators should be kept clean. Review of the facility's 2021 service manual, [machinery make/model name] 5-Liter Oxygen Concentrator Service Manual, indicated, Cleaning: The recommended cleaning interval for the air filter is 7 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555204 If continuation sheet Page 12 of 12