Health inspection·August 22, 2023

F 0686 Review of Resident 1's Braden scale assessment (tool used in wound assessment) dated 2/9/23 indicated, she had a score of 14 (a score of 13-14 represents a moderate risk for developing pressure ulcers). Level of Harm - Actual harm Residents Affected - Few 1. Review of Resident 1's admission Evaluation assessment dated [DATE], indicated resident's primary admitting diagnosis was, encounter for after care following surgery, and identified the presence of a cast on Resident 1's right lower leg. Review of Resident 1's orthopedic surgeon's progress notes dated 2/17/23, indicated a CAM boot was applied to the right lower leg. Review of Resident 1's clinical record indicated there was no care plan initiated for Resident 1's use of the CAM boot. There were no nursing measures in place to assess the skin and monitor the skin integrity of Resident 1's right lower leg. During an interview and concurrent record review with the director of nursing (DON) on 7/31/23 at 11:05 a.m., she stated there was a care plan developed for Resident 1's cast on admission but confirmed there was no care plan developed for the CAM boot when it was applied to Resident 1's right lower extremity on 2/17/23. The DON stated the facility should have developed a care plan specifically for the CAM boot to include nursing interventions to monitor the skin, reposition and monitor for pressure related injury. When the DON was asked how nursing staff was assessing the skin on Resident 1's right lower leg, she responded we could not do any skin assessments of Resident 1's right lower leg because we were not taking the CAM boot off. Review of the facility's policy titled Comprehensive Person-Centered Care Plans, revised March 2022, indicated assessments of residents are ongoing and care plans are revised as information about the resident and the resident's conditions change. 2. Review of Resident 1's orthopedic doctor's progress notes, dated 2/17/23, indicated, Sutures removed; strips applied; leave strips to fall off; no dressing required; CAM boot applied; WBAT (weight bearing as tolerated) in CAM boot RLE (right lower extremity); shower OK; continue gentle PT (physical therapy)/OT (occupational therapy); patient should only bear weight as tolerated; Call with questions. During an interview and concurrent record review with the nursing supervisor (NS) on 6/15/23 at 2:00 p.m., she was asked if Resident 1's record indicated any doctor's orders for the CAM boot, specifically if there were any doctor's orders indicating if the CAM boot could be removed or if it was to be worn 24 hours a day. The NS stated, I do not see any orders for the CAM boot . Some doctors have the boot always stay on. The NS was questioned if the 2/17/23 physician's progress note entry, shower OK, indicated the boot can be taken off for a shower. She responded, I can't tell from this physician's progress note .it does not say . There are no specific doctor's orders about the CAM boot . If I were the one to receive this physician's progress note, I would have called the orthopedic doctor to clarify if the CAM boot could be removed for the shower. The NS stated Resident 1's physician should have been called to obtain orders related to removal of the CAM boot. During an interview and concurrent record review with the DON on 7/7/23 at 1:30 p.m., she acknowledged there were no doctor's orders for Resident 1's CAM boot and no specific order to indicate if the CAM boot could be removed by facility staff. She stated a variety of boots and splints are worn by their residents and the orders to remove them will vary according to their physicians. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 2 of 4 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 08/22/2023 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 0686 Level of Harm - Actual harm Residents Affected - Few stated, since there were no orders to remove Resident 1's CAM boot, the staff did not remove it. She further stated that Resident 1, Had a fracture and we did not want to do anything that would disrupt the healing process; so, we never took the CAM boot off. She acknowledged the staff should have called Resident 1's orthopedic doctor to clarify what she wanted in terms of the CAM boot for this resident. The DON stated, If there are questions about when to wear it or if it should be taken off, then we should ask the doctor. A review of Resident 1's (nursing) clinical notes report, dated 3/11/23, indicated Resident 1's son removed the CAM boot and requested a licensed nurse do a skin assessment of Resident 1's right lower leg. The report also indicated dark brown discolored skin was observed on Resident 1's right foot located at the right heel measuring 3 centimeters (cm, unit of measure) by 3 cm and at the right upper plantar area (area of the bottom of the foot opposite the heel) measuring 3 cm by 3 cm. The report indicated the licensed nurse contacted Resident 1's medical doctor and received orders to treat the deep tissue injuries on Resident 1's right foot. During an interview with Resident 1's orthopedic surgeon (OS, physician specializing in correcting bone and muscle deformities) on 7/13/23 at 3:00 p.m., she was asked if Resident 1's pressure ulcers on the right lower leg could be attributed to the wearing of the CAM boot. The OS stated, 100% .the DTIs can be attributed to the CAM boot .I was surprised that they were not removing it. She further stated the CAM boot is a removable device and the expectation is that the skin will be assessed at regular intervals, and the CAM boot would be removed in order to accomplish this. The OS stated the nursing staff should, certainly have a plan of care for removable orthosis (brace or other devices to correct alignment or provide support) that involves skin checks .that is just typically done as a nursing measure. 3. Review of Resident 1's Internal Medicine History and Physical, dated 2/10/23, indicated she had a diagnosis of fracture of the right tibia and had an open reduction and internal fixation (ORIF, type of surgery used to stabilize and heal a broken bone) on 2/2/23 in the acute hospital prior to her admission to the facility. Review of Resident 1's admission Evaluation Assessment, dated 2/9/23, indicated Resident 1 was admitted with a cast on her right lower leg (which was removed during an appointment with her orthopedic surgeon on 2/17/23). Review of a physician progress note, dated 2/17/23, indicated, sutures removed; strips applied .leave strips to fall off; no dressing required . During an interview and concurrent record review with the DON on 7/31/23 at 11:05 a.m., she acknowledged Resident 1 had a surgical repair of her fractured right lower leg. The DON was asked if the surgical site should be monitored after the cast was removed from Resident 1's right lower leg on 2/17/23. The DON stated there are physician orders for care of a surgical site, dressing changes, and monitoring for signs of infection when residents have had surgical procedures. She further stated, There are no physician orders for surgical site care of Resident 1's right lower leg . In this resident's case, the CAM boot was left on and there were no treatments done to the surgical site. When the DON was asked if a surgical site should be monitored until healed, she stated, Yes surgical sites should be monitored .I do not see any orders to monitor the surgical site for Resident 1 .the CAM boot remained on; so, we did not monitor the surgical site. 4. During a phone interview with the orthopedic technician (OT), from Resident 1's orthopedic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 3 of 4 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 08/22/2023 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 0686 Level of Harm - Actual harm Residents Affected - Few surgeon's office on 7/31/23 at 4:30 p.m., she stated Resident 1 was fitted with an immobilization device to the right lower leg during her orthopedic appointment on 2/17/23. The OT identified the make and model of Resident 1's immobilization device applied. A review of the manufacturer's guidelines for this device indicated, Caution: Be sure the patient performs circulation checks. If a loss of circulation is felt, or if the walker feels too tight, release contact closure straps and adjust to a comfortable level. If discomfort continues, the patient should contact their medical professional immediately. Review of Resident 1's physician order dated 2/10/23 indicated, Cast Care: Cast on right lower leg. Monitor for foul odors, changes in sensation, swelling, burning, numbness, tingling, skin discoloration, paralysis, white or cool toes or fingertips, warm spots, soft areas, cracks in cast. Notify MD as needed. A review of the treatment administration record (TAR) indicated licensed nurses followed the physician order for cast care and monitored Resident 1's casted right lower extremity from 2/10/23 until 2/21/23. There was no documented monitoring of Resident 1's right lower leg after the cast was removed and the CAM boot was applied on 2/17/23. During an interview and concurrent record review with the licensed vocational nurse A (LVN A) on 7/17/23 at 1:00 p.m., she acknowledged Resident 1 had a CAM boot applied on her right lower leg on 2/17/23. When LVN A was asked what nursing measures would be initiated when a resident is wearing a CAM boot, she replied, I would expect to do checks on the affected part in the CAM boot, check for color, circulation, movement, and pain. LVN A reviewed Resident 1's clinical record and acknowledged there was no documentation indicating monitoring was done for Resident 1's right lower leg when the CAM boot was in place and LVN A stated there should be. Review of the facility's policy titled Prevention of Pressure Injuries, revised April 2020, indicated for device-related pressure injuries to monitor regularly for comfort and signs of pressure-related injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 4 of 4