Health inspection·November 9, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete developed the care plan for Resident 1 who was admitted after hip surgery. The DON stated the care plan should include any activity limitations and precautions, use of devices, and include nursing interventions specific to Resident 1's post operative course. Review of the facility's policy 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: a. includes measurable objectives and timeframes; b. Describes the services that are to be furnished .; and . e. reflects currently recognized standards of practice for problem areas and conditions. Event ID: Facility ID: 555547 If continuation sheet Page 2 of 5 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 11/09/2023 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician orders for one of three residents (Resident 1) when: Residents Affected - Few 1. A physician order for Resident 1's use of an abduction pillow (device used to separate the legs and stabilize the hips) was not carried out upon admission to the facility; and, 2. The facility staff failed to transcribe the physician orders for hip precautions (restrictions for after having a total hip replacement), and use of an abduction hip brace (device to maintain correct body alignment and reduce the risk of dislocation) on the Treatment Administration Record (TAR). These failures prevented the Resident 1 from receiving the necessary treatment prescribed by the physician and had the potential for joint repair dislocation, which would jeopardize the rehabilitation of Resident 1. Findings: Review of Resident 1's face sheet (brief summary of a resident's important information) indicated she was admitted on [DATE] with diagnoses including aftercare following joint replacement surgery, presence of right artificial hip joint, dementia (a decline in mental capacity affecting daily function), difficulty in walking, muscle wasting and atrophy (decrease in size). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 6/10/22, indicated she had a BIMS (Brief Interview for Mental Status) score of 6 (a score of 0 to 7 indicates severe cognitive [i.e. thinking, reasoning, or remembering] impairment). Resident 1 required extensive assistance (requiring staff to provide weight-bearing support) for bed mobility (moving in bed), and toileting. Resident 1 was dependent on staff for transfers and had impaired range of motion (the full movement potential of a joint) in the right lower extremity. 1. Review of Resident 1's acute hospital Discharge Orders/Instructions, dated 6/6/22, indicated, physical activity restricted, Abduction Pillow while in bed. Review of Resident 1's skilled nursing medical record revealed there was no physician order for an abduction pillow while in bed and there was no documentation that the facility was using an abduction pillow for Resident 1. During an interview and concurrent record review with registered nurse A (RN A) on 9/27/23 at 4:25 p.m., he stated he was the facility's admission nurse and had admitted Resident 1 on 6/6/22. RN A was asked about Resident 1's hospital discharge order for an abduction pillow while in bed. He confirmed there was an order for an abduction pillow and stated, I don't see that I carried that order out . I don't know how I missed that. RN A stated, The abduction pillow should be transcribed as an order and will appear on the TAR. The nurses will initial every shift that the abduction pillow is in place. RN A stated the licensed nurse's documentation is necessary to show the facility is following the physician order for the abduction pillow to be used by Resident 1 while in bed. 2. Review of Resident 1's Physician Order, dated 6/6/22, that indicated, Total hip precautions: No hip flexion greater than 70 degrees, no hip adduction (movement towards the midline of the body), no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 3 of 5 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 11/09/2023 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 0658 internal rotation of operative hip. These positions can cause the hip to dislocate (displaced from its normal position). Level of Harm - Actual harm Residents Affected - Few Review of Resident 1's Physician Order, dated 6/6/22, that indicated, Weight bearing as tolerated. Weight bearing on the right lower extremity with hip abduction brace when out of bed. Review of Resident 1's medical record revealed there was no documentation that the facility was following total hip precautions as ordered by the physician, and no documentation that Resident 1 was using a hip abduction brace when she was out of bed. During an interview and concurrent record review with registered nurse A (RN A) on 9/27/23 at 4:25 p.m., he confirmed Resident 1 had physician orders for total hip precautions and to use a hip abduction brace when out of bed. RN A stated the orders were not transcribed correctly; so, the orders did not appear on Resident 1's TAR. RN A stated, I don't know what happened, the orders need to be on the TAR. He confirmed there was no documentation the facility was observing total hip precautions or using a hip abduction brace when Resident 1 was out of bed. During an interview and concurrent record review with the nursing supervisor (NS) on 10/5/23 at 11:58 a.m., she was asked to review Resident 1's orders for total hip precautions and a hip abduction brace when out of bed. The NS was asked where in Resident 1's record the licensed nurses document that total hip precautions were observed and that Resident 1 used a hip abduction brace when out of bed. The NS stated, I don't know why those orders are not in Resident 1's TAR . they should be. That's where the licensed nurses will document. The NS stated when the abduction brace and total hip precaution orders are transcribed correctly, they will appear on the TAR. The nurses will initial every shift they are observing total hip precautions and the abduction brace is in place as ordered. NS indicated the licensed nurses' documentation is necessary to show the facility is following the physician orders. The NS confirmed there was no documentation the facility was observing total hip precautions or using a hip abduction brace for Resident 1. Review of Resident 1's Clinical Notes – Nursing Progress Notes, dated 6/24/22, indicated an order was received from Resident 1's physician for x-rays of bilateral hips. Review of the Radiology Report, dated 6/25/22, indicated right femoral arthroplasty (thigh reconstructed joint) dislocated from the parent acetabulum (socket part of the hip joint). Review of Resident 1's Clinical Notes – Nursing Progress Notes, dated 6/27/22, indicated physician orders to send Resident 1 to the emergency room for further evaluation. Review of Resident 1's Emergency Department – Provider Notes, History and Physical, dated 6/27/22, indicated Resident 1 was unable to adequately work in physical therapy due to pain. An assessment X-ray report indicated Resident 1 had a dislocation of the right hip and to admit to orthopedics for reduction (bone realignment) in the OR (operating room). Review of the California Nursing Practice Act Rules and Regulations, Division 2, Chapter 6, Article 2. Scope of Regulations 2725 (b) indicated, The practice of nursing within the meaning of this chapter means . (2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist (medical specialist for treatment of foot problems), or clinical psychologist (specialist (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555547 If continuation sheet Page 4 of 5 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 11/09/2023 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 0658 in the treatment of mental, emotional, and behavioral disorders), as defined by Section 1316.5 of the Health and Safety Code. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility's policy titled Charting and Documentation, revised 12/2022, indicated documentation of treatments should include the date and time the treatment was provided, the name and title of the individual who provided the care, any assessment data obtained during the treatment, and whether the resident refused the treatment. Event ID: Facility ID: 555547 If continuation sheet Page 5 of 5