Health inspection·November 14, 2022

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete indicated, All reports of resident abuse, including injuries of unknown origin, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies, as required by current regulations and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as, within two hours of an allegation involving abuse or result in serious bodily injury; or within twenty-four hours of an allegation that does not involve abuse or result in serious bodily injury. All allegations are thoroughly investigated. The administrator, or his/her designee, provide the appropriate agencies with a written report of the findings of the investigation within five working days of the occurrence of the incident. The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. Event ID: Facility ID: 555547 If continuation sheet Page 2 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete the discharge Minimum Data Set (MDS, an assessment tool) for one of three residents (Resident 57). Failure to accurately assess had the potential to compromise the facility's ability to provide resident-centered discharge care planning and interventions for the resident. Residents Affected - Few Findings: Review of Resident 57's discharge summary report indicated he was discharged to an assisted living facility (ALF) on 8/13/22. During an interview with registered nurse D (RN D) on 11/9/22 at 1:42 p.m., she verified that Resident 57 was discharged to an ALF on 8/13/22. Review of Resident 57's discharge MDS, dated [DATE], indicated he was discharged to the acute hospital. During an interview and concurrent record review with the director of nursing (DON) on 11/9/22 at 4:43 p.m., the DON confirmed the coding for Resident 57's discharge MDS was incorrect. The DON verified Resident 57 was discharged to an ALF, not to the acute hospital. The DON explained there was a licensed vocational nurse (LVN) working remotely part-time as MDS coordinator. The LVN coded Resident 57's discharge MDS incorrectly and the previous DON signed it. During an interview with the Minimum Data Set Coordinator (MDSC) on 11/10/22 at 9:35 a.m., the MDSC also verified that Resident 57s discharge MDS was incorrectly coded. The MDSC stated Resident 57 was not discharged to the acute hospital, but to an ALF. Review of the Centers for Medicare and Medicaid Services (CMS) 10/2019 Resident Assessment Instrument 3.0 User's Manual (RAI Manual, MDS coding instructions) indicated for section A2100, Discharge Status, Code 01, community, if discharge location is assisted living facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 3 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 provide care and services in accordance with professional standards of practice when: Residents Affected - Some 1. Staff did not implement the facility's policy for four of seven residents (Residents 163, 166, 59 and 209) with pacemakers or automatic implantable cardioverter-defibrillators (surgically implanted devices that help control the heartbeat); and 2. Staff did not implement the facility's protocol after discovering a skin discoloration for one of 13 sampled residents (Resident 24). These failures had the potential to negatively affect the residents' health, safety and well-being. Findings: 1a. Review of Resident 163's medical record indicated he was admitted on [DATE] and had the diagnosis of heart failure (the heart does not pump blood as well as it should). During an interview with Resident 163 on 11/10/22 at 10:23 a.m., he stated he had a pacemaker and that he has had it for several years. Resident 163's family member, who was present during this interview, confirmed Resident 163's statement. Review of Resident 163's Physician Order Sheet indicated he had an order, dated 11/2/22, to monitor for pacemaker malfunction every shift. Further review of Resident 163's medical record indicated there was no documentation of the paced rate (the number of heartbeats per minute that should be maintained by the pacemaker), the type and model of the pacemaker, the serial number, or the address and phone number of the cardiologist (heart doctor). There were no documented instructions on how to monitor Resident 163's pacemaker battery. There was no identification card that indicated Resident 163 had a pacemaker. There was no care plan to address Resident 163's pacemaker. During an interview and concurrent record review with the nurse supervisor (NS) on 11/10/22 at 10:27 a.m., she reviewed Resident 163's medical record and confirmed the above pacemaker information was not present. She acknowledged the facility should have obtained the information. The NS confirmed Resident 163 did not have a care plan to address his pacemaker and acknowledged the facility should have developed one. During an interview with licensed vocational nurse C (LVN C) on 11/10/22 at 10:51 a.m., he stated he checked Resident 163's heart rate in the morning. When asked if the heart rate was within Resident 163's paced rate, LVN C stated he did not know. LVN C was also unable to explain how to monitor Resident 163's pacemaker battery. 1b. Review of Resident 166's medical record indicated she was admitted on [DATE] and had the diagnoses of atrial fibrillation (type of irregular heart rate or rhythm) and presence of cardiac pacemaker. The medical record did not have documentation of the paced rate for Resident 166's pacemaker. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 4 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 59's medical record indicated she was admitted on [DATE] and had the diagnoses of heart failure and presence of cardiac pacemaker. There was no identification card in the medical record that indicated Resident 59 had a pacemaker. Review of Resident 209's medical record indicated he was admitted on [DATE] and had the diagnoses of atrial fibrillation and presence of cardiac pacemaker. The medical record did not have documentation of the paced rate for Resident 209's pacemaker. The medical record did not have documentation that Resident 209 had an electrocardiogram (EKG, a test that monitors heart activity) since he was admitted to the facility (nearly one and a half years ago). During an interview and concurrent record review with the director of nursing (DON) on 11/14/22, the DON reviewed the medical records of Residents 166, 59 and 209. The DON confirmed the above pacemaker information was not in the residents' medical records. Review of the facility's policy titled Pacemaker, Care of a Resident With, revised 12/2015, indicated for each resident with a pacemaker, document the following information in the medical record: 1. Name, address and telephone number of the cardiologist; 2. Type of pacemaker; 3. Type of leads; 4. Manufacturer and model; 5. Serial number; 6. Date of implant; and 7. Paced rate. The policy further indicated, The pacemaker battery will be monitored remotely through the telephone or an internet connection. The resident's cardiologist will provide instructions on how and when to do this. The resident will have an EKG annually, or as ordered, to monitor for changes in the heart's electrical activity. Make sure the resident has a medical identification card that indicates he or she has a pacemaker. The medical record must contain this information as well. 2. During an observation and concurrent interview with Resident 24 on 11/7/22 at 11:07 a.m., Resident 24 had a round, purple discoloration, slightly larger than a thumb print, on his right lateral arm at elbow level. Resident 24 stated he did not know how he got the discoloration. He stated he informed a staff member about it and was still waiting to hear back. During an interview with certified nursing assistant B (CNA B) on 11/7/22 at 11:08 a.m., CNA B confirmed that she reported Resident 24's discoloration to the nurse. Review of Resident 24's medical record was conducted on 11/10/22 (three days after the right arm discoloration was discovered). The medical record did not have any documentation regarding the discoloration on Resident 24's right arm. During an interview and concurrent record review with the NS on 11/10/22 at 8:45 a.m., she explained what facility staff were supposed to do when they discovered a discoloration on a resident. The NS stated a new skin discoloration was considered a change of condition. The nurse should document the incident, develop a care plan, measure the discoloration, notify the resident's family and doctor, obtain an order to monitor the discoloration for any changes, and document this monitoring on the treatment administration record (TAR). The NS added that the interdisciplinary team (IDT, staff from different departments who work together to plan and provide care) should conduct an investigation to determine how the resident acquired the discoloration. The NS reviewed Resident 24's medical record and confirmed there was no documentation that the nurse did any of these things after CNA B reported that Resident 24 had a right arm discoloration. The NS also confirmed Resident 24's right arm discoloration was new, as there was no previous documentation about it. Review of the facility's policy titled Skin Tears - Abrasions and Minor Breaks, Care of, revised (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 5 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 9/2013, indicated when a bruise is discovered, complete a report of the incident. The policy further indicated to complete an in-house investigation of causation, generate a Non-Pressure form (used to document size and other characteristics of the discoloration), document physician and family notification, document interventions, and document any complications. Review of the facility's policy titled Change in a Resident's Condition or Status, revised 2/2021, indicated the nurse will notify the resident's attending physician when there has been discovery of injuries of an unknown source. Review of the facility's policy titled Care Plans - Comprehensive Person-Centered, revised 3/2022, indicated a comprehensive, person-centered care plan is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the facility's policy titled Charting and Documentation, revised 7/2017, indicated any changes in the resident's condition and all services provided to the resident shall be documented in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 6 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 209's clinical record indicated he was admitted on [DATE] and had the diagnoses of Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements), history of falling and difficulty in walking. Review of Resident 209's Postfall Assessment, dated 6/23/22, indicated the Brief Physical and Cognitive Assessment was not completed. Review of Resident 209's Postfall Assessment, dated 8/11/22, indicated the Brief Physical and Cognitive Assessment (Physical Status Prior to Fall and Current Medication Use) was incomplete. Review of Resident 209's Postfall Assessment, dated 10/26/22, indicated the Brief Physical and Cognitive Assessment was not completed. During an interview and concurrent record review with the NS on 11/14/22 at 2:30 p.m., the NS confirmed Resident 209's Postfall Assessments on 6/23/22, 8/11/22, and 10/26/22 were incomplete. NS stated Postfall Assessments should be completed. Review of the facility's policy titled Falls - Clinical Protocol, revised 3/2018, indicated the nurse shall assess and document musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. The policy further indicated the nurse shall assess and document all current medications and changes in cognition, level of consciousness and neurological status. Review of the facility's policy titled Charting and Documentation, revised 7/2017, indicated documentation in the medical record will be complete and accurate. Based on observation, interview and record review, the facility failed to completely assess two of 13 sampled residents (Residents 1 and 209) after fall incidents when: 1. For Resident 1, the facility did not do fall risk assessments after two falls; and 2. For Resident 209, the facility did not complete post-fall assessments after three falls. These failures had the potential to increase the recurrence of falls and to compromise the facility's ability to anticipate and implement interventions to prevent future falls. Findings: 1. Review of resident 1's clinical record indicated she had falls on 1/21/22, 3/17/22, 7/30/22 and 10/31/22. There was no documentation that the facility did fall risk assessments after Resident 1 fell on 1/21/22 and 3/17/22. Further review of Resident 1's clinical record indicated she was an elderly female with the diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions), dementia (loss of memory) with behavioral disturbances, chronic obstructive pulmonary disease (COPD, inflammatory lung disease that causes obstructed airflow), history of transient ischemic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 7 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few attack (TIA, temporary blockage of blood flow to the brain), generalized muscle weakness, chronic atrial fibrillation (irregular heartbeat), presence of prosthetic heart valve (designed to replicate the function of native valves by maintaining unidirectional blood flow) and history of falling. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 10/13/22, indicated she had a Brief Interview for Mental Status (BIMS) score of 8 (a score of 8 to 12 indicates moderate cognitive impairment). During a concurrent observation and interview with Resident 1 on 11/9/22 at 9:10 a.m., Resident 1 was in her room, sitting in her wheelchair and just had her breakfast. She had a dark brown discoloration on the upper right area of her face. Resident 1 verified that she just had a fall recently, but could not recall details of the incident. During a concurrent interview and review of Resident 1's clinical record with the Director of Nursing (DON) on 11/14/22 at 2:24 p.m., the DON verified the facility did not do fall risk assessments after Resident 1 fell on 1/21/22 an 3/17/22. During an interview with the nurse supervisor (NS) on 11/14/22 at 2:35 p.m., the NS verified that after each fall, the nurse assigned to the resident should do a fall risk assessment. Review of the facility's Nursing Services Policy and Procedures Manual for Long-Term Care: Fall Risk Assessment, revised March 2018, indicated, The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 8 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide respiratory care in accordance with professional standards of practice for two of 13 sampled residents (Residents 163 and 4) when: Residents Affected - Few 1. For Resident 163, the facility did not implement its policy regarding continuous positive airway pressure (CPAP, device that uses a hose connected to a mask to deliver air and keep the airway open during sleep) and did not develop a care plan to address his use of a CPAP machine. Also for Resident 163, the facility did not store his oxygen tubing according to policy. 2. For Resident 4, the facility did not develop a care plan to address her use of oxygen. Failure to implement the CPAP policy compromised the facility's ability to ensure Resident 163 was receiving the correct amount of air pressure to keep his airway open during sleep. Failure to properly store oxygen tubing put Resident 163 at risk for respiratory infection. Failure to develop care plans put the residents at risk for not receiving necessary care and interventions. Findings: 1. During an observation on 11/10/22 at 6:59 a.m., Resident 163 was lying in bed asleep. He had a mask covering his nose with tubing connected to a CPAP machine. The numbers on the CPAP machine were fluctuating between 9.0 and 10.1. Next to Resident 163's bed, there was an oxygen concentrator (machine used to deliver oxygen) with a nasal cannula (flexible tubing that goes into the nostrils) attached to it. There was a blue bag attached to the oxygen concentrator. The nasal cannula was not in use, but it was not stored in the blue bag. It was hanging down the side of the oxygen concentrator. During an observation and concurrent interview with the nurse supervisor (NS) on 11/10/22 at 7:10 a.m., she confirmed the numbers on Resident 163's CPAP machine were fluctuating between 9.0 and 10.1. The NS also confirmed Resident 163's nasal cannula was hanging down the side of the oxygen concentrator. The NS confirmed the nasal cannula should have been stored in the blue bag that was attached to the oxygen concentrator. The NS acknowledged this was an infection control issue. Review of Resident 163's Physician Order Sheet indicated he had an order, dated 11/2/22 for, May have pre-set CPAP on at bedtime. Off in the morning. Or as needed when in bed asleep. There was no documentation in the order, or elsewhere in the medical record, indicating what Resident 163's preset CPAP settings were. There was also no care plan to address Resident 163's use of a CPAP machine. During an interview and concurrent record review with licensed vocational nurse G (LVN G) on 11/10/22 at 7:32 a.m., LVN G confirmed she was Resident 163's nurse during the night shift. LVN G was unable to state what Resident 163's preset CPAP settings were. She reviewed Resident 163's medical record and confirmed there was no documentation indicating what the preset CPAP settings were. LVN G acknowledged the CPAP settings should be documented in the medical record so when the nurses looked at the numbers on the machine, they could verify if the machine was running at the correct settings. LVN G also confirmed Resident 163 did not have a care plan to address his use of a CPAP machine. She acknowledged the facility should have developed a care plan. Review of the facility's policy titled CPAP/BiPAP Support, revised 3/2015, indicated to review the physician's order to determine the oxygen concentration and flow, and the pressure for the machine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 9 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The policy further indicated to document the mode and settings for the CPAP machine in the medical record. Review of the facility's policy titled Departmental (Respiratory Therapy) - Prevention of Infection, revised 11/2011 indicated, Keep the oxygen cannulae and tubing used PRN [as needed] in a plastic bag when not in use. 2. A record review of Resident 4's physician orders, dated November 2022, indicated Resident 4 had an order for Oxygen at 2 liters (oxygen flow rate) as needed starting on 9/20/22. A review of Resident 4's medical record indicated there was no oxygen care noted on the care plan. During an interview with the NS on 11/14/22 at 11:45 a.m., the NS stated that the nurse who received the oxygen order should develop a care plan to address the use of oxygen. During an interview with the director of nursing (DON) on 11/14/22 at 1:33 p.m., the DON stated the residents who receive oxygen should have oxygen care in the care plan. A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 3/2022 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 10 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor the side effects related to the use of Eliquis (an anticoagulant [blood thinner] medication that interrupts the formation of blood clots) for three of 13 sampled residents (Residents 11, 16 and 6). This failure had the potential to affect the residents' physical well-being while in the facility. Residents Affected - Some Findings: 1. Review of Resident 11's clinical record indicated he was admitted on [DATE] and had the diagnosis of atrial fibrillation (irregular heart rate). Review of Resident 11's Physician's Order Sheet, dated November 2022, indicated, Eliquis 2.5 milligrams (mg, unit of measurement) tablet oral two times daily. Review of Resident 16's clinical record indicated he was admitted on [DATE] and had the diagnosis of atrial fibrillation. Review of Resident 16's Physician's Order Sheet, dated November 2022, indicated, Eliquis 2.5 mg tablet oral every 12 hours. During an interview and concurrent record review with the nurse supervisor (NS) on 11/10/22 at 4:30 p.m., the NS reviewed Resident 11 and Resident 16's MAR (Medication Administration Record) and TAR (Treatment Administration Record) and confirmed there was no documentation of monitoring for side effects of Eliquis. The NS further stated residents on anticoagulants should be monitored for signs and symptoms of bleeding. 2. A record review of Resident 6's Physician Order, dated November 2022, indicated, Eliquis 5 mg tablets oral twice a day started on 6/1/2022. A review of Resident 6's MAR and TAR, from June 2022 to October 2022, indicated there was no documentation of monitoring for side effects while on Eliquis. During an interview with the NS on 11/14/22 at 11:30 a.m., the NS confirmed there was no documentation of Eliquis side effects monitoring in Resident 6's record. The NS further stated the nurses should monitor residents on Eliquis for signs of bleeding. During an interview with the director of nursing (DON) on 11/14/22 at 1:33 p.m., the DON stated the nurses should monitor and document anticoagulant medication side effects. Review of facility's policy titled Anticoagulation - Clinical Protocol, revised 11/2018, indicated, Assess for any signs and symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. Assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to that particular drug (for example, a resident with an above therapeutic level of an anticoagulant medication should be assessed for bleeding.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 11 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to monitor for side effects and target behaviors (behaviors intended to be changed or eliminated by medications) for one of seven residents (Resident 163) who received psychotropic medications (medications that cause changes in mood, feelings or behavior). This failure had the potential to compromise the facility's ability to determine if the psychotropic medications were effective. This failure also put Resident 163 at risk for experiencing harmful effects from the medications. Findings: Review of Resident 163's medical record indicated he had a physician's order, dated 11/2/22, for Paroxetine (medication used to treat depression) 10 milligrams (mg, unit of dose measurement) by mouth daily. There was no target behavior specified in the Paroxetine order. Resident 163 also had a physician's order, dated 11/2/22, for Lorazepam (medication used to treat anxiety) 0.5 mg by mouth at hour of sleep (bedtime). There was no target behavior specified in the Lorazepam order. Review of Resident 163's 11/2022 medication administration record (MAR) indicated he received the above medications every day, starting on 11/3/22. Further review of Resident 163's medical record indicated there was no documentation of side effects monitoring or target behavior monitoring for Paroxetine and Lorazepam. During an interview with the nurse supervisor (NS) on 11/9/22 at 9:48 a.m., she explained that for residents receiving psychotropic medications, nurses should monitor for side effects every shift and document this on the MAR or treatment administration record (TAR). The NS confirmed each psychotropic medication should have a specific target behavior. She stated the nurses should monitor for target behaviors every shift and document this on the MAR or TAR. During an interview and concurrent record review with the NS on 11/10/22 at 10:27 a.m., the NS reviewed Resident 163's medical record and confirmed there was no documentation of side effects monitoring or target behavior monitoring for Paroxetine and Lorazepam. Review of the facility's policy titled Medication Monitoring Medication Management, dated 1/2022 indicated, When monitoring a resident receiving psychotropic medications, the facility must evaluate the effectiveness of the medications as well as look for potential adverse consequences. The policy further indicated the clinical record must reflect whether there is adequate monitoring for the effectiveness of the medication in treating the specific condition and for any adverse consequences resulting from the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 12 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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 a 7.69% medication error rate when two medication errors out of 26 opportunities were observed during medication passes for two of six residents (Residents 16 and 3). These failures resulted in medications not being given in accordance with the prescriber's orders and/or manufacturer's specifications, which could have resulted in the residents not receiving the full therapeutic effects of the medications. Residents Affected - Few Findings: During a medication pass observation on 11/8/22 at 8:45 a.m., licensed vocational nurse C (LVN C) was observed preparing and administering morning medications to Resident 16. LVN C did not prepare and administer folic acid (a B vitamin that helps the body make healthy new cells), which was scheduled to be administered to Resident 16 at 9:00 a.m. During an interview with LVN C on 11/9/22 at 8:37 a.m., LVN C acknowledged he did not prepare and administer folic acid to Resident 16. A review of Resident 16's Physician Order Sheet, dated November 2022, indicated he was scheduled to receive folic acid 1 milligram (mg, unit of dose measurement) by mouth one time a day. The medication was scheduled to be administered at 9:00 a.m. During a medication pass observation on 11/10/22 at 7:19 a.m., registered nurse D (RN D) was observed preparing and administering morning medications to Resident 3. RN D did not prepare and administer the nasal spray, which was scheduled to be administered to Resident 3 at 8:00 a.m. During an interview with RN D on 11/10/22 at 9:25 a.m., RN D acknowledged she did not prepare and administer the nasal spray to Resident 3. A review of Resident 3's Physician Order Sheet, dated November 2022, indicated she was scheduled to receive nasal spray at 8:00 a.m. A review of the facility's policy titled Administering Medications, revised April 2019, indicated medications must be administered in accordance with the orders, including any required time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 13 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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. Based on observation, interview and document review, the facility failed to label medications in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable, in one of two medication carts. This failure had the potential to result in administration of expired medications. Findings: During a concurrent observation and interview with licensed vocational nurse E (LVN E) on 11/9/22 at 4:45 p.m., in front of Medication Cart 2, one bottle of refresh tears 0.5% eye drops for Resident 7 was not labeled with an open date. LVN E stated it should be labeled with the residents' name, room number and open date. During an interview with the director of nursing (DON) on 11/14/22 at 1:33 p.m., the DON stated eye drops should be labeled with the open date to prevent nurses from administering expired medications. A review of the facility's policy titled Administering Medications, revised April 2019, indicated the expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 14 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: 1. Two kitchen personnel were not wearing hair nets and one kitchen staff's hair was not completely covered; 2. Thawed chicken in the walk-in refrigerator was undated; 3. Dried tomatoes were not discarded by the good thru date on the label; 4. A box of popcorn kernels in the dry storage was not tightly sealed; and 5. Wild rice and a bottle of mayonnaise did not have an expiration date on the label. These failures had the potential to cause food borne illnesses to the residents in the facility. Findings: 1. During an observation on 11/7/22 at 8:50 a.m., the dietary manager (DM) and dietary director (DD) were not wearing hair nets while in the kitchen. During another observation on 11/9/22 at 9:50 a.m., a kitchen staff (KS) only placed the hairnet on the crown of his head, which did not effectively cover all his hair. During an interview with the registered dietitian (RD) on 11/9/22 at 10:30 a.m., the RD was made aware of the above observations. The RD stated hair nets or hats should be worn when in the kitchen and should cover the entire hair. Review of the facility's policy titled Dress Guidelines For Food Service Management and Clinical Nutrition Staff, revised 1/2021 indicated, Hair restraints are worn by all when in the kitchen. This includes department associates, associates from other facility departments and guests, such as vendors. 2. During an observation and concurrent interview with the RD on 11/7/22, at 9:40 a.m, there were two boxes of thawed chicken in the walk-in refrigerator. The boxes were undated. The RD stated they should be dated and consumed within three days once thawed. Review of the facility's undated policy titled Food Handling Guidelines indicated, Thaw Frozen Meat/Poultry/Seafood: Label with the date it was removed from the freezer, and date by which it must be used. 3. During an observation and concurrent interview with the RD on 11/9/22 at 9:22 a.m., there was a container of dried tomatoes in the dry storage area. The label indicated: Good thru date of 10/27/2022. The RD stated it should be removed from the shelf. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 15 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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 facility's policy titled Food and Supply Storage, dated 1/2018, indicated, Foods past the use by, sell by, best by, or enjoy by date should be discarded. 4. During an observation and a concurrent interview with the RD on 11/7/22, at 9:27 a.m., while in the dry storage area, there were popcorn kernels placed inside a box that was not tightly sealed. The tape used to seal the box was already loose. The RD stated it should be covered. Review of the facility's policy titled Food and Supply Storage, dated 1/2018, indicated, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. 5. During an observation and concurrent interview with the RD on 11/7/22 at 9:33 a.m., there was wild rice wrapped in plastic in the dry storage area and a bottle of mayonnaise in the walk-in refrigerator with no expiration date on the label. The RD stated they should be labeled with the expiration date. Review of the facility's policy titled Food and Supply Storage, dated 1/2018, indicated, Cover, label and date unused portions and open packages. Use the [NAME] orange label complete all sections on the label. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 16 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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 Based on observation, interview and record review, the facility failed to implement infection control and prevention practices when: Residents Affected - Some 1. Certified nursing assistant A (CNA A) was not screened for Coronavirus Disease 2019 (COVID-19, a contagious viral infection that can cause severe respiratory symptoms) before entering the facility and providing resident care; 2. Staff did not perform hand hygiene and medical equipment sanitization during medication pass; 3. Staff did not change gloves between tasks; and 4. Staff did not change Q-tips and did not label a dressing during wound treatment. These failures had the potential to result in transmission and spread of infection in the facility. Findings: 1. During an observation on 11/7/22 at 10:54 a.m., CNA A was in Resident 60's room assisting her back into bed. Review of the facility's Nursing Assignment Sheet, dated 11/7/22, indicated CNA A was assigned to provide care for seven residents. Review of the facility's COVID-19 screening log, dated 11/7/22, indicated there was no documentation that CNA A was screened for COVID-19 prior to entering the facility and providing resident care. During an interview with the infection preventionist (IP) on 11/7/22 at 3:27 p.m., she stated all employees and visitors must be screened for COVID-19 before entering the facility. During a follow-up interview and concurrent record review with the IP on 11/7/22 at 4:13 p.m., she reviewed the facility's COVID-19 screening log and confirmed there was no documentation that CNA A was screened prior to entering the facility. Review of the Centers for Disease Control and Prevention's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/23/22 indicated, Establish a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following three criteria: 1) a positive viral test for SARS-CoV-2 [virus that causes COVID-19], 2) symptoms of COVID-19, or 3) close contact with someone with SARS-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for healthcare personnel (HCP)). Review of the facility's policy titled COVID-19 Transmission Prevention Guide For Healthcare Professionals, dated 3/30/2020 indicated, All healthcare professionals must sign-in and be screened at the designated entrance. 2. During a medication administration observation with licensed vocational nurse C (LVN C) on 11/8/22 at 8:40 a.m., outside Resident 61's room, LVN C did not wash or sanitize his hands before (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 17 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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 entering the resident's room and administering oral medication. Level of Harm - Minimal harm or potential for actual harm During a medication administration observation with LVN C on 11/8/22 at 8:45 a.m., in Resident 16's room, LVN C did not clean the blood pressure machine and cuff, which he used for resident 61 and then brought it into resident 16's room to check his blood pressure. LVN C also did not wash or sanitize his hands before administering oral medications. Residents Affected - Some During a medication administration observation with LVN C on 11/8/22 at 9:02 a.m., outside Resident 60's room, LVN C did not clean the blood pressure machine and cuff just used for resident 16 and brought it into Resident 60's room to check her blood pressure. During a medication administration observation with LVN C on 11/8/22 at 9:10 a.m., in resident 160's room, LVN C did not wash or sanitize his hands before entering the resident's room and administering oral medications. During a follow-up interview on 11/8/22 at 9:30 a.m., LVN C confirmed the above observations. He stated he should have sanitized his hands before administering medications. He further stated he should have cleaned the blood pressure machine and cuff before reusing it for different residents to prevent cross contamination. 3. During a medication administration observation with registered nurse H (RN H) on 11/9/22 at 4:30 p.m., in Resident 16's room, RN H did not wash or sanitize her hands before wearing a pair of gloves to clean the resident's hand using an alcohol wipe. Without changing gloves, she used the same gloved hands to clean Resident 16's abdomen with alcohol wipes and injected insulin. During a follow-up interview on 11/9/22 at 4:37 p.m., RN H confirmed the above observation. She stated she should have changed gloves before administering insulin. 4. During a wound Vacuum Assisted Closure (VAC) (a negative pressure wound therapy for difficult wounds) dressing change observation with the wound care nurse (WCN) on 11/10/22 at 3:22 p.m., in Resident 10's room, the WCN did not dispose of the used Q-tip after first time use and reused it to apply a new piece of foam into the resident's stage 4 pressure ulcer (wound resulting from prolonged pressure) on the coccyx (tailbone) area. The WCN did not label the dressing with the date, time and her initials after the dressing change. During a follow-up interview on 11/10/22 at 3:52 p.m., the WCN confirmed the above observations. She stated she should have disposed of the used Q-tip and opened a new Q-tip to apply a new piece of foam into the resident's wound. She also stated she should label the dressing with date, time and her initials. During an interview with the director of nursing (DON) on 11/14/22 at 1:33 p.m., the DON stated staff should wash or sanitize their hands before and after entering residents' rooms, before administering medications, between tasks and between changing gloves. The DON further stated that the nurse should not reuse Q-tips during wound dressing changes to prevent cross contamination, and the wound dressing should be labeled with the date, time and nurse's initials. A review of the facility's policy, revised 8/2019 and titled Handwashing/Hand Hygiene, indicated all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .use an alcohol-based hand rub containing at least (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 18 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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 62% alcohol; or alternatively, soap and water for the following situations: before and after direct contact with residents; before preparing and handling medications . A review of the facility's policy, revised 10/2018 and titled Cleaning and Disinfection of Resident-care Items and Equipment, indicated durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions .single use items will be discarded after a single use . Event ID: Facility ID: 555547 If continuation sheet Page 19 of 20 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 555547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to designate an Infection Preventionist (IP) that had completed specialized training in infection prevention and control when their current IP did not have an IP certificate. This failure had the potential to compromise the facility's infection prevention and control programs (IPCP) for the residents residing in the facility. Findings: During an interview with the IP on 11/9/22 at 1:54 p.m., she verified that she started working as IP on 10/25/22. She said that the last day of the previous IP, registered nurse I (RN I), working as full-time IP, was last month. The IP further stated that she did not have the IP certificate yet. She stated she still needed 17 hours of online training before she could get her IP certificate. The IP also said that her back-up IP during weekdays was the director of staff development (DSD) and during weekends, was the health services administrator (HSA). During an interview with DSD on 11/9/22 at 4:10 p.m., the DSD verified she was the back-up IP during weekdays but did not have an IP certificate. The DSD further stated she had not started the online training needed to get the IP certificate. During a separate interview with HSA on 11/9/22 at 4:10 p.m., he verified that he was the back-up IP during weekends, but did not have the IP certificate. During another interview with the HSA on 11/10/22 at 5:25 p.m., he verified that only RN I had an IP certificate. During an interview with RN I on 11/14/22 at 11:49 a.m., she verified that she was the previous IP, but her last day as full-time IP was 10/5/22. Review of the facility's policy, Infection Preventionist: Job Description: Work Duties, dated 7/8/2020, indicated, The Infection Preventionist is responsible for the facility infection prevention and control program which is designed to provide safe, sanitary and comfortable environment, and to help prevent development and transmission of communicable diseases and infections. California Communities require a full time Infection Preventionist position, which may be shared by two or more individuals. The California Infection Preventionist is responsible to: provide staff training, maintain and periodically update the community COVID-19 mitigation plan in collaboration with the leadership team and current available best practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 20 of 20