Health inspection·March 21, 2024

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 interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three sampled residents (Resident 1) when there was no documentation that licensed nurses notified the physician that Resident 1 did not receive multiple medications. Failure to notify the physician had the potential to result in additional orders not being received and carried out as needed. Residents Affected - Few Findings: Review of Resident 1 ' s medical record indicated Resident 1 was admitted to the facility on [DATE] at 9:20 p.m. Resident 1 had diagnoses including osteomyelitis (a bone infection), Parkinson ' s Disease (a disorder of the nervous system that affects movement), dementia (a mental disorder caused by brain disease or injury), duodenal ulcer (a sore in part of the intestine), and gout (a type of arthritis [joint tenderness and swelling] that causes pain and stiffness). Review of Resident 1 ' s medication administration record (MAR), dated 1/2024, indicated Resident 1 was scheduled to receive the following medications: 1.) Amlodipine (medication used to treat high blood pressure) 5 milligrams (mg, unit of dose measurement) to be administered at 9:00 a.m.; 2.) Ascorbic acid (vitamin C) 250 mg to be administered at 9:00 a.m.; 3.) Rytary (medication used to treat Parkinson ' s Disease) 48.7 mg– 195 mg 2 capsules to be administered at 5:00 a.m.; 4.) Colchicine (medication used to treat gout) 0.6 mg to be administered at 9:00 a.m.; 5.) Flector 1.3% transdermal patch (pain medication applied to the skin) to be applied at 9:00 a.m.; 6.) Febuxostat (medication used to treat gout) 40 mg to be administered at 9:00 a.m.; 7.) Pantoprazole (medication that reduces stomach acid) 40 mg to be administered at 11:30 a.m.; 8.) Polyethylene glycol (medication used to prevent constipation) 17 grams (gm, unit of dose measurement) to be administered at 9:00 a.m.; 9.) Sucralfate (medication used to treat ulcers in the intestines) 100 mg per milliliter (mg/ml, unit of dose measurement) to be administered at 9:00 a.m.; and 10.) Valproic acid (medication used to treat seizures but can also be used as a mood stabilizer) 250 mg/ml to be administered at 2:00 p.m. Further review of Resident 1 ' s MAR indicated for the above scheduled medications, the documentation was highlighted in grey on 1/24/24. The last four pages of the MAR indicated for amlodipine 5mg, ascorbic acid 250 mg, Rytary 48.75 – 195 mg, colchicine 0.6mg, Flector 1.3% transdermal patch, and febuxostat 40 mg, the documentation was highlighted in grey on 1/24/24 because the medications were not administered to Resident 1. The MAR did not indicate why the documentation was highlighted in grey for pantoprazole 40 mg, polyethylene glycol 17 gm, sucralfate 100 mg/ml, and valproic acid 250 mg/ml. Review of Resident 1 ' s Daily Skilled Progress Notes, dated 1/24/24, indicated the facility was, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555547 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 03/21/2024 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)