The Terraces of los Gatos

In the surveyor’s words

From the most serious findings on record at The Terraces of los Gatos, in the surveyor’s own words.

• Actual harm, isolatedF658Nov 9, 2023

  Based on interview and record review, the facility failed to follow physician orders for one of three residents (Resident 1) when: 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). […]

• Actual harm, isolatedF686Aug 22, 2023

  Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) received necessary care and services to achieve and maintain her highest practicable health and well-being when: 1. Staff did not develop an individualized resident-centered care plan to address Resident 1's use of a CAM (controlled ankle movement) boot, 2. Licensed nurses did not follow-up with the physician for clarification of instructions for Resident 1's CAM boot, 3. Licensed nurses did not assess and monitor Resident 1's surgical incision on the right ankle, and 4. […]

• Actual harm, isolatedF600Jan 4, 2023

  Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from abuse when Resident 1 alleged a facility staff of sexually assaulted Resident 1, the facility did not inform the primary physician regarding the sexual assault allegation and did not have evidence that staffs provided a follow-up monitoring of Resident 1 after the allegation of sexual abuse. Resident 1's care plan was not updated to address the abuse allegation, and the facility did not report the sexual abuse allegation to the California Department of Public Health (CDPH). […]

• No harm, potential for more than minimal, patternF684Nov 14, 2022

  Based on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice when: 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF757Nov 14, 2022

  Based on interview and record review, the facility failed to monitor the side effects related to the use of [MEDICATION(S)] (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. Findings: 1. Review of Resident 11's clinical record indicated he was admitted on [DATE] and had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 11's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 16's clinical record indicated he was admitted on [DATE] and had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]