Health inspection·May 7, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some acknowledged Resident 91 had episodes of involuntary movements that could result in her accidental clothes removal. She stated the staff should regularly check the resident to make sure her clothes were on and that she had privacy. Review of Resident 91's clinical record indicated she had diagnoses of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), dementia (a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and Huntington's disease (a fatal genetic disorder that causes the progressive breakdown of nerve cells in the brain). Review of Resident 91's Minimum Data Set (MDS, a clinical assessment tool) dated 3/22/21, indicated she had severely impaired cognitive skills. Her dressing required extensive assistance and two-person physical assist. A review of the facility's policy titled Resident's Rights dated 1/15/2007, indicated residents shall have the right to be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 3. During an observation on 5/3/21, at 11:30 a.m., Resident 106 was observed with an uncovered urinary catheter drainage bag hanging from his wheelchair while the occupational therapist (OT) was wheeling him in the hallway outside his room. During a concurrent observation and interview on 5/3/21 at 11:37 a.m. with the OT, she confirmed the above observation and stated Resident 106 should have bag covering the urinary catheter drainage bag when outside his room. During an interview on 5/3/21 at 11:46 a.m. with licensed vocational nurse M (LVN M), he stated Resident 106 should have a blue dignity bag covering the urinary catheter drainage bag when in his wheelchair. A review of the facility's undated policy titled Foley Catheter Care indicated care of foley bag . Protect residents' privacy and dignity by placing cover over foley bag when resident is out of bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 2 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 0637 Assess the resident when there is a significant change in condition 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 complete a significant change in status assessment (SCSA) in the minimum data set (MDS, an assessment tool) for one of 25 sampled residents (87) when the resident had significant weight loss, had declined in activities of daily living (ADL, daily self-care tasks, e.g., bathing, toileting, and transferring) and had declined bowel continence. Residents Affected - Few These failures had the potential to result in Resident 87 unable to achieve or maintain optimal status of health, function and quality of life. Findings: Review of Resident 87's face sheet (summary page of a patient's important information) indicated he was readmitted to the facility on [DATE] with diagnoses including dysphagia (difficulty of swallowing), major depressive disorder (mood disorder that interferes with daily life) and schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior). During a concurrent interview and record review on 5/7/21 at 1:41 p.m., with registered dietitian BB (RD BB), she reviewed the clinical records of Resident 87 and stated the ideal body weight (IBW) is 130 lbs.-155 lbs. and his height is 5'6. She further stated that Resident 87 was below his IBW. During a concurrent interview and record review on 5/7/21 at 2:08 p.m., with the RD BB, she reviewed the clinical records of Resident 87 and stated readmission weight on 9/25/21 was 114 lbs., on 10/24/21, weight is 105 lbs. She further stated that Resident 87 had a 7.8% weight loss in a month. During a concurrent interview and record review on 5/7/21 at 3:52 p.m., with RD BB, she reviewed the weight variance committee meeting notes dated 10/26/2020. She stated there was no nursing staff present during the discussion about Resident 89's weights and the director of nursing was aware about weight loss of 5 % or more in the last 30 days. She further stated that the weight loss of Resident 87 was unplanned. Review of Resident 87's MDS dated [DATE], indicated his cognition (mental, thought processes) and brief interview for mental status (BIMS, cognition level) score of four is severely impaired. He required extensive assistance with two persons assist in activities of daily living (ADL), locomotion on unit indicate activity occurred only once or twice, walk in room needs limited assistance with one person assist and locomotion off unit did not occur over seven day period. His bowel continence is frequently incontinent- two or more episodes of bowel incontinence but at least one continent bowel movement. Review of Resident 87's MDS dated [DATE], he required extensive assistance with more than two people physical assist with bed mobility, dressing and personal hygiene. Eating required extensive assistance with one-person assist, locomotion on unit and locomotion off unit did not occur over seven day period and for transfer activity occurred only once or twice with one person physical assist. His bowel continence is always incontinent-no episode of continent bowel movement. During an interview and concurrent record review with minimum data set coordinator D (MDSC D) on 5/7/21 at 4:11 p.m., he reviewed the RD notes, care plan and weight variance meeting notes and confirmed that Resident 87 had a weight loss of 7.8 % within 30 days. He stated he was not aware of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 3 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few weight loss and if he had known about the unplanned weight loss, a comprehensive assessment should have been done within 14 days from the determination of the significant change in status. During a concurrent interview and record review on 5/7/21 at 4:30 p.m. with MDSC D, he reviewed the MDS dated [DATE] and 9/25/2020. He stated Resident 87 had two or more decline in ADL's, declined bowel continence and a weight loss of 7.8 % within the last 30 days from the readmission weight on 9/25/21 was 114 lbs., on 10/24/21, weight is 105 lbs. MDSC D confirmed there was no evidence a SCSA comprehensive assessment was done and no interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) discussion about criteria of a SCSA. Review of Resident Assessment Instrument Manual 3.0 Version 1.16.1, dated 10/2018, indicated .a significant change in status assessment must be completed on the fourteenth calendar day after determination that a significant change in the resident's status occurred. The manual further indicated a SCSA MDS is appropriate when a resident declined in two or more areas or the emergence of an unplanned weight loss problem . Review of the facility's general policy guidelines revision dated 10/29/2015, titled Weight Management, indicated a weight management committee (IDT) will review all significant weight variances. All residents with significant weight change will be discuss in the weight committee, stand -up meeting and /or care conferences (IDT). Any significant weight change that may require a new MDS according to RAI guidelines will be evaluated by the IDT. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 4 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan with measurable objectives, goal and person-centered interventions, for one of 25 sampled residents (118). This deficient practice had the potential to result not meeting the resident's needs. Findings: During an observation on 5/3/21 at 10:21 a.m., Resident 118 was lying in bed, with a fall mat on the floor next to his bed and had a low bed. Resident 118 had unclear speech, slurred and mumbled words. A review of Resident 118's face sheet indicated he was readmitted to the facility on [DATE], with diagnoses that included Schizophrenia (chronic brain disorder characterized by hallucinations, disorganized thoughts and speech, and trouble thinking), Alzheimer's (a progressive disease that destroys memory and mental functions), dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Anxiety disorder (medical condition includes symptoms of intense anxiety or panic that are directly caused by a physical health problem.) and type 2 diabetes mellitus(high blood sugar). Review of Resident 118's minimum data set (MDS, an assessment tool) dated 4/8/21, indicated his cognition (mental, thought processes) and a brief interview for mental status (BIMS, cognition level) score of three is severely impaired. He required extensive assistance with one person physical assist in activities of daily living (ADL), non-ambulatory, wheelchair locomotion on and off unit did not occur and transfer activity did occur but only one or twice in seven days from bed to wheelchair. His speech was unclear; he slurred or mumbled words and only sometimes understands. A review of Resident 118's Fall Risk assessment dated [DATE], indicated a fall risk score of 17 (High Risk = 10 or above). A review of Resident 118's Care plan dated 7/7/17 indicated Resident 118 was at risk for falls due to psychoactive drug use, impaired physical function, gait or balance problem and behavior issues related to diagnosis of dementia and schizophrenia. During a concurrent interview and record review on 5/5/21 at 4:47 p.m., with the assistant director of nursing (ADON), she reviewed Resident 118's baseline Fall Care Plan dated 7/7/17 and 4/23/21. She stated most of the fall interventions on the care plan were not relevant to the resident. Resident 118 could not walk, and providing non-skid footwear, ensure usage when ambulating and propelling himself in his wheelchair did not apply, providing verbal cues, encouragement and frequent reminders to ask for assistance using the call light when getting in and out of bed were not meaningful interventions. Resident 118 was not cognitively aware and was not capable of using the call light to ask for help. The ADON further stated it was her expectation for care plans to be individualized, resident specific, realistic and measurable goal and implemented. A review of Resident 118's interdisciplinary team (IDT, team members from different disciplines (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 5 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 0656 Level of Harm - Minimal harm or potential for actual harm involved in a resident's care) notes dated 4/26/21, indicated fall incident occurred on 4/23/21 a.m. shift and found on the floor next to his bed. Further investigation of the IDT, Resident 118 was asleep prior to fall incident and no episode of getting out of bed. Resident 118 was send out to emergency department (ED) on 4/23/21 after fall incident for further medical evaluation and treatment due to Resident 118 complained of head, back and hip pain. Residents Affected - Few During an interview and concurrent record review with minimum data set coordinator D (MDSC D) on 5/5/21 at 5:48 p.m., he reviewed the short-term fall care plan dated 4/23/21. Care plan indicated Resident 118 had episode of unwitnessed fall and the goal was will have no complications related to unwitnessed fall through the review date 4/30/21. MDSC D confirmed that the care plan goal was not reviewed and updated until 5/2/21 and was late for revision. He further stated the care plan was not person centered, individualized, resident centered, objective and goal was not realistic and measurable, and most of the interventions was not applicable with the Resident 118's status or condition. Review of the facility's policy dated 9/1/13, titled Care Planning indicated care plan consisted of three main components: problem statement or nursing diagnosis (may also include resident/client strength) for which goals and interventions are developed, Goal(s) which are resident/client oriented, are time-limited, and that are realistic and measurable in order to monitor the resident/client's progress, Intervention(s) which are measures and actions put in place to assist the resident/client to reach their goal, and include the assigned discipline or person responsible to perform the intervention and care plans are reviewed no less than quarterly with the resident assessment schedule and revised as needed to meet the needs of the resident/client. Review of the facility's policy dated 9/1/13, titled Fall Prevention & Management indicated Nurses are to evaluate the resident's fall prevention care plan weekly for effectiveness/outcome. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 6 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 117's admission record indicated he was admitted to the facility on [DATE] with chronic obstructive pulmonary disease (COPD, a disease that causes airflow blockage and breathing-related problems.) Residents Affected - Few Review of Resident 117's physician order indicated he had an order for oxygen 2 liter (L, a metric unit of volume) per minute (LPM) to 5 LPM as needed every shift related to COPD. During an observation with licensed vocational nurse C (LVN C) on 5/3/21 at 10:25 a.m., Resident 117 was lying in bed and was administered oxygen at 1.25 LPM. During a concurrent interview with LVN C, she confirmed Resident 117 was administered oxygen at 1.25 LPM. LVN C stated it should have been 2LPM. Review of the facility's 9/1/13 policy, Physician Orders indicated Licensed nursing personnel will ensure that telephone and verbal orders will be recorded and implemented. Based on observation, interview, and record review, the facility failed to ensure services provided meet professional standards for two of 25 sampled residents (88 and 117) when: 1. Resident 88's feeding pump was not turned off during medication administration to ensure flow of medication towards the resident's feeding tube. 2. Resident 117's oxygen flow rate was not followed according to the physician's order. These failures had the potential to compromise residents' safety and needs. Findings: 1. During an observation on 5/5/21 at 4:27 p.m., while LVN J was administering medication to Resident 88's feeding tube, the feeding pump was still running. LVN J did not turn off the feeding pump. Also, LVN J did not close the 3-way valve to ensure flow of medication given towards the patient. The port was open towards the feeding solution and resident's stoma. During an interview with LVN J on 5/5/21 at 4:28 p.m., LVN J stated she should have turned off the feeding pump and closed the 3-way valve towards the feeding solution before giving the medication. Review of the facility's policy and procedure titled Enteral Therapy (Tube Management, Feeding, Medications) dated 9/1/13, procedure for administering medication indicated 2. Prior to administering medication, stop the feeding and flush the tube with at least 15 cc water . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 7 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 the necessary care to maintain good grooming and personal hygiene for one of four residents (84). This failure resulted in Resident 84 having long and dirty fingernails and long toenails. Residents Affected - Few Findings: Review of Resident 84's admission record indicated he was admitted to the facility on [DATE] with diabetes diagnosis (a disease in which the blood sugar levels are too high.) Review of Resident 84's Minimum Data Set (MDS, a clinical assessment tool), dated 12/28/2020, indicated Resident 84 needed extensive assistance with one-person physical assistance for personal hygiene. During an observation on 5/3/21 at 11:46 a.m., Resident 84 was lying in bed. His fingernails and toenails were long, and his fingernails were dirty. During a concurrent interview with supervisor A (SUP A), she confirmed Resident 84's fingernails and toenails were long, and his fingernails were dirty. SUP A stated sometimes Resident 84 refused to have his nails cut. Review Resident 84's physician order indicated he had an order for podiatry care and treatment every 60 days and as needed dated 1/30/14. During an interview with social service director B (SSD B) on 5/5/21 at 3:33 p.m., she stated Resident 84's fingernails should be trimmed by licensed nurse and his toenails should be trimmed by the podiatrist. SSD B confirmed that the last time Resident 84 received podiatric treatment was on 2/18/21. SSD B stated a podiatric treatment should have been scheduled for Resident 84 in 4/2021. During an interview with SUP A on 5/5/21 at 3:56 p.m., she was unable to provide the document about Resident 84's refusal of his nails to be cut. Review of the facility's 9/1/13 policy Fingernails and Toenails, Care of indicated Fingernails and toenails are cleaned and trimmed regularly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 8 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview and record review, the facility failed to ensure bladder care was provided for one of five residents with indwelling urinary catheter (hollow tube that is inserted into your bladder to drain urine) when Resident 329's urinary collection bag was not emptied. This failure had the potential to cause resident's urinary tract infection (when bacteria gets into urine and travels up to bladder). Findings: During an observation on 5/4/21 at 3:30 p.m., Resident 329's urinary collection bag was full, bulky and hanging beside the bed. It contained more than 1000 ml of amber urine . During an interview with LVN K on 5/04/21 at 3:32 p.m., LVN K stated the urinary collection bag was not emptied since this morning and should have been emptied on every shift to avoid it becoming too full and heavy, which may pull on the catheter. This should occur every 2 to 3 hours or when the bag is about half to three-quarters full. Review of Resident 329's physician order dated 1/25/21, indicated Catheter care daily (per facility protocol) - AM every day shift. Review of Resident 329's care plan to address risk for urinary system alteration related to retention of urine secondary to benign prostatic hyperplasia, obstructive uropathy and renal stone, revised date 9/30/2020, indicated Check resident for incontinence during rounds at least every 2 hours and assist with pericare as needed .Provide catheter care as ordered The facility's undated policy and procedure titled Foley Catheter Care, indicated .1. Empty drainage bag every shift . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 9 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 5/3/21 at 9:59 a.m., Resident 87's was lying in bed with his breakfast tray untouched and uncovered on top of his bedside table. Residents Affected - Few During an observation and concurrent interview with LVN M on 5/3/21 at 11:17 a.m., he confirmed the above observation. He stated the CNA assigned to Resident 87 did not ask for food replacements and/or offer a food substitute; and lunch would be served soon. During an observation on 5/3/21 at 12:30 p.m., Resident 87's was lying in bed with his lunch tray untouched and uncovered on top of his bedside table. During an observation and concurrent interview with LVN M on 5/3/21 at 1:15 p.m., he confirmed the above observation. He stated the CNA assigned to Resident 87 did not ask for a food substitute and the lunch tray was served around 12:40 p.m. He further stated the food was already cold and needed to be replaced. During multiple observations on 5/4/21 at 8:15 a.m., 5/5/21 at 8:49 a.m., 5/6/21 at 8:45 a.m., and 5/7/21 at 10:00 a.m., Resident 87's was lying in bed with his breakfast tray was untouched and uncovered on top of his bedside table. During an observation and concurrent interview with CNA AA on 5/6/21 at 8:55 a.m.,she confirmed Resident 87 did not eat breakfast on 5/4/21, 5/5/21 and 5/6/21. She stated the charge nurse was notified about the refusal and she forgot to ask the kitchen for a substitute meal tray . During a concurrent interview and record review on 5/7/21 at 1:45 p.m., she stated Resident 87 had been refusing meals. Nursing staff removed his meal tray without offering a replacement food tray or should have offerd a substitute meal tray if the food remained untouched or refused. She further stated that certain food should not be left behind for longer periods as it may get spoiled or contaminated. Review of Resident 87's face sheet (summary page of a patient's important information) indicated he was readmitted to the facility on [DATE] with diagnoses including dysphagia (difficulty of swallowing), major depressive disorder (mood disorder that interferes with daily life) and schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior). Review of Resident 87's MDS dated [DATE], indicated his cognition (mental, thought processes) and brief interview for mental status (BIMS, cognition level) score of six severely impaired and eating required extensive assistance with one-person assist. Review of Resident 87's clinical record he is on mechanical soft texture diet due to difficulty of swallowing. A review of the facility's undated policy titled Food Substitution for Residents Who Refuse the Meal, indicated suitable nourishing alternate meal after planned, served meal has been refused. Nursing personnel will question any resident who does not eat his meal or food item as to why he is not eating and offer a food substitution in accordance with the resident's diet order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 10 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 0692 Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure two of 11 sampled residents (75 and 87) were not offered and provided food substitution during meal refusals. This failure had the potential to result in altered nutritional status and unplanned weight loss for the residents. Residents Affected - Few Findings: 1. During an observation and concurrent interview with licensed vocational nurse E (LVN E) on 5/4/21 at 3:24 p.m., Resident 75 was sitting in bed reading his newspaper. An untouched and uncovered lunch tray was on top of his overhead table. LVN E confirmed the observation and stated Resident 75's lunch tray was served around 12:30 p.m. She confirmed the food was already cold and would need to be replaced. During an interview with registered dietician G (RD G) on 5/4/21 at 3:45 p.m., she confirmed the lunch trays were served starting at 11:30 a.m. and stated nursing staff should offer a substitute meal tray if the food remained untouched or refused. During an interview with registered dietician H (RD H) on 5/5/21 at 10:14 a.m., she stated Resident 75 eats slow and sometimes would not allow the staff to remove his meal tray without offering replacement food tray. She acknowledged certain food should not be left behind for longer periods as it may get spoiled or contaminated. RD H also stated the lunch tray should be taken away by 2 p.m. and staff should offer an alternate meal. During an interview with certified nursing assistant F (CNA F) on 5/6/21 at 7:46 a.m., she remembered Resident 75 did not eat his lunch last Tuesday, 5/4/21. She acknowledged not taking away his lunch tray and did not offer a replacement food until her shift ended at 3 p.m. Review of Resident 75's clinical record indicated he had diagnoses of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning) and dysphagia (swallowing difficulties). He was on pureed texture and nectar thick liquid. He refuses to wear dentures. Review of Resident 75's latest minimum data set (MDS, an assessment tool), indicated he had moderately impaired cognitive skills. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 11 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 10.71 percent medication error rate when three (3) medication errors of 28 opportunities were identified during a medication pass for three of seven residents. These failures had the potential to result in an ineffective drug therapy and possible adverse events. Residents Affected - Few Findings: 1. During an observation on 5/4/21 at 8:45 a.m., LVN E poured 15 ml of Centrum liquid (Multivita.m.in & Mineral liquid) over piston (irrigation) syringe to Resident 46's gastrostomy (G-tube, feeding tube placed through the abdomen into the stomach). The medication was not fully administered when there was about one-third back flow of the multivita.m.in liquid spilled out from the piston syringe that was orange colored. During an interview with LVN E on 5/04/21 at 9:00 a.m., LVN E stated only about three-fourth of the multivita.m.in liquid was given to Resident 46 because the medication spilled out from the syringe. Review of Resident 46's physician order for 5/2021, indicated Multivita.m.in & Mineral liquid. Give 15 ml via G-tube one time a day for supplement. 2. During an observation on 05/6/21 at 8:36 a.m., LVN L crushed the tablet of lithium carbonate (treatment for mood disorder) 300 milligra.m. (mg, unit of mass) and administered via G- tube. Since 9:30 a.m. Resident 83's breakfast meal-tray was placed on the bedside table and was not consumed. During an interview with LVN L on 5/6/21 at 9:30 a.m., LVN L stated Resident 83 had not eaten her breakfast. LVN L acknowledged that she should have waited Resident 83 to consume her breakfast before giving her the medication to prevent an upset stomach. Review of Resident 83's medication packet for lithium carbonate, label indicated Take with food and plenty of water. 3. During an observation on 5/6/21 at 9:33 a.m., LVN L gave ferrous sulfate (iron supplement) 325 mg tablet instead of ferrous fumarate 325 mg to Resident 33. During an interview with LVN L at 11:10 a.m., LVN L stated there was no available stock of ferrous fumarate. She further stated they have been giving the resident ferrous sulfate all this time. Review of Resident 33's physician order for 5/2021, indicated Ferrous Fumarate 325 mg. Give 1 tablet by mouth one time a day for supplement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 12 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly store medications and biologicals when: 1. An expired bottle of loperamide (anti-diarrhea) was found in one of the medication carts in Station B; 2. A bottle of Haloperidol (used to treat mental disorder) not kept in its original carton to protect from light was found in medication cart in Station A; 3. A Zioptan (sterile eye drop solution) single use containers not stored in refrigerator was found in the medication cart in Station A; and 4. Two boxes containing normal saline (NS, a mixture of sodium chloride in water that has a number of uses in medicine) were left outside the building. This failure had the potential to affect the efficacy and potency of the drugs. Findings: 1. During an observation on [DATE] at 2:40 p.m., in Station B, there was a bottle of Loperamide HCl (anti-diarrhea) containing several pills which had an expiration date of 11/2020 found in the top drawer of the medication cart. During an interview with LVN M, on [DATE] at 2:35 p.m., LVN M stated the loperamide should have been discarded since last year. Review of the policy and procedure titled Storing and Safe Handling of Drugs revised date 6/11, indicated I. Drugs are not to be kept on hand after the expiration date that appears on the label. Outdated, contaminated, or deteriorated drugs and those in containers that are cracked, soiled, or without secure closures are to be immediately withdrawn from stock, reordered from the pharmacy if a current order exists for any client, and disposed of in accordance with procedures for drug destruction. 2. During an observation on [DATE] at 3:24 p.m., in Station A, there was a 120 ml bottle of Haloperidol oral solution (2 mg/ml) kept in a clear plastic in the medication cart. The label indicated Store at controlled room temperature. Protect from light. During an interview with LVN N on [DATE] at 3:25 p.m., LVN N stated the bottle should be stored in the original carton to protect from light. 3. During an observation on [DATE] at 3:45 p.m., in Station A, there was a Zioptan (tafluprost ophthalmic solution) found in the medication cart. Its label indicated Refrigerate (2 to 8 degrees Celsius or 36 to 46 degrees Fahrenheit. During an interview with LVN O on [DATE] at 3:46 p.m., LVN O stated, that should have been refrigerated since then. The resident who owns it was transferred to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 13 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 - Some 4. During an environmental tour with the Infection Preventionist (IP) on [DATE] at 7:55 a.m., a large push cart containing boxes of normal saline (NS, a mixture of sodium chloride in water that has a number of uses in medicine), medicine plastic cups, surgical drapes, and personal protective equipment (PPE) were under the tree next to the parking lot. During an interview with central supply staff I (CSS-I) on [DATE] at 8:15 a.m., he stated the supplies were delivered yesterday afternoon. However, he decided not to put them inside the building because his shift was almost over. When asked if it was safe to leave the NS boxes overnight outside the building, CSS-I stated it did not matter since it was only use for flushing. During an interview with the IP on [DATE] at 8:30 a.m., he confirmed the observation and stated the NS should be safely stored inside the building at a room temperature. During an interview with the Administrator (ADM) on [DATE] at 10:30 a.m., she acknowledged the NS should be stored in room temperature and not to be left outside the building. She also stated the facility had allocated a designated space where to put the medical supplies. The facility's policy and procedure titled Storing and Safe Handling of Drugs dated 06/2011, indicated drugs and biologicals are to be stored in a secure and orderly manner under proper temperatures and are to be accessible only to licensed nursing and pharmacy personnel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 14 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when: Residents Affected - Some 1. Ten dietary staff did not cover their hair completely with a hairnet; 2. Two cans of dried peas in the dry storage room were dented; 3. Chopping boards 2 of 7 had deep cuts; and 4. Two dietary staff used the same potholder that was dropped on the floor to hold the hot tray and pots. These failures had the potential to result in a food borne illness outbreak among a population of vulnerable residents with complex medical conditions. Findings: 1. During an initial kitchen tour with the dietary manager (DM) on 5/3/21 at 9:15 a.m., the DM, registered dietitian (RD), dietary aide (DA) DA Q, DA R, DA S, DA T, DA U, DA V, DA W and DA X, worked in the kitchen. Their hair on the sides and back were not completely covered with a hair net. During an interview with the DM on 5/3/21 at 9:25 a.m., she confirmed the above observation and she stated dietary staff should have covered their hair completely with a hair net. Review of the facility's policy, DRESS CODE FOR WOMEN AND MEN, dated 2018 indicated, .Appropriate dress in the Food & Nutrition Department Personal hygiene and appropriate dress are a very important part of the total appearance of the Food & Nutrition Services Department. The policy indicated women should wear .Hair net or hat which completely covers the hair . and men should wear .Hat for hair, if hair is short .Hair net for hair, if hair is long (over the ears or longer) . 2. During an initial kitchen tour with the DM on 5/3/21 at 9:43 a.m., she confirmed two cans of dried peas in the dry storage room were dented and were not removed to prevent use. A review of the facility document titled Food Storage- Dented Cans, indicated Food in unlabeled, broken containers or cans with side seam dents, rim dents or swells shall not be retained or used by the facility. All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for returns to purveyor for refund. According to the United States Food and Drug Administration (FDA, a federal agency) indicated, A sharp dent on either the top or side seam can damage the seam and allow bacteria to enter the can. Discard any can with a deep dent on any seam. 3. During a concurrent observation and interview on 5/4/21 at 11:26 a.m., with the DM, she acknowledge that two chopping boards had deep cuts and stated she needed to replace the chopping boards. 4. During an observation in the kitchen on 5/4/21 at 11:05 a.m., dietary cook Y (DC Y) grabbed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 15 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 potholder and then dropped the potholder on the floor, he picked it up and used it to hold the lasagna tray to put inside the oven and then put the potholder on top of the grill. During an interview with DC Y on 5/4/21 at 11:10 a.m., he confirmed the above observation and stated that he should not had used the potholder to hold the lasagna tray inside the oven due to infection control issue. Residents Affected - Some During an observation in the kitchen on 5/4/21 at 11:10 a.m., DA Z grabbed the potholder that was dropped on the floor and placed on top of the grill by DC Y and used it to hold the hot dog pot and boiled eggs pot. During a concurrent observation and interview on 5/4/21 at 11:26 a.m., with DA Z, she confirmed the above observation and stated she should not have used the potholder that was dropped on the floor due to contamination. A review of the facility document titled, Sanitation indicated all utensils, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 16 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure documentation was complete for two of six residents (84 and 94) when Resident 84 and Resident 94 restorative nursing assistance (RNA) order were not transcribed to the Restorative Flow Sheet (RFS). These failures resulted in Residents 84 and 94 not receiving a RNA as ordered. Findings: 1. Review of Resident 84's admission Record indicated he was admitted to the facility on [DATE] with muscle weakness diagnosis. Review of Resident 84's physician order indicated he had an RNA order for active assisted range of motion (AAROM) or passive range of motion (PROM) of bilateral upper extremity in all planes while supine in bed as tolerated three times a week for three months, dated 4/23/21. However, this order was not on Resident 84's 5/2021 RFS. During an interview with minimum data set coordinator D (MDSC D) on 5/7/21 at 1:35 p.m., he confirmed the order was not on Resident 84's 5/2021 RFS, and therefore Resident 84 had not received this RNA service. 2. Review of Resident 94's admission Record indicated she was admitted to the facility on [DATE] with unsteadiness on feet diagnosis. Review of Resident 94's physician order indicated she had an RNA order for AAROM/PROM for bilateral lower extremity as tolerated (two sets of 10 repetitions) three times a week for three months, dated 2/10/21. However, this order was not on Resident 94's RFS from 2/2021 to 5/2021. During an interview with MDSC D on 5/7/21 at 1:29 p.m., he confirmed the order was not on Resident 94's RFS from 2/2021 to 5/2021, and therefore Resident 94 had not received this RNA service. Review of the facility's 9/1/13 policy Restorative Nursing Program, indicated The nursing or physician order will be transcribed to a Restorative Flow sheet, to be initialed as completed by the Certified Nursing Assistant or Restorative Nursing Assistant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 17 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. During an observation on 5/3/21 at 10:07 a.m., Resident 78 had signage outside his door and one pair of used gloves and two disposable gowns were exposed outside the garbage lid. Residents Affected - Many During a concurrent observation and interview on 5/3/21 at 10:08 a.m., with LVN M, he confirmed the above observation and stated the garbage can was overflowing and the housekeeper should empty the garbage can. He further stated that Resident 78 is on contact isolation precaution and staff should have disposed the used gowns and pair of gloves inside the garbage can with fully covered by the lid. During an observation on 5/6/21 at 8:25 a.m., Resident 78 had signage outside his door and two pairs of used gloves, two disposable gowns were expose outside the garbage lid cover. During a concurrent observation and interview on 5/6/21 at 8:30 a.m., with LVN K, he acknowledged the above observation. He stated the garbage can was full and the housekeeper should empty the garbage can. He further stated that the overflowing of used gloves and gowns in the garbage can was against infection control. 9. During an observation on 5/3/21 at 10:32 a.m., activity assistant (ACA) was inside the room of Resident 78 and he was wearing a facemask, face shield, disposable gown and gloves. During an observation on 5/3/21 at 10:33 a.m., ACA removed the gown and gloves outside Resident 78's room and disposed of then inside the trash can that was attached to the medication cart, parked across the hallway. During concurrent observation and interview on 5/3/2021 at 10:34 a.m., with ACA, he acknowledged the above observation. He stated that he did not know where to dispose the used gown and gloves. He further stated that Resident 78 is on contact isolation precaution. Review of Resident 78's clinical records indicated he was on contact and droplet precaution for observation following exposure to his roommate with an episode of vomiting on 4/25/21. 10. During an observation on 5/3/21 at 11:30 a.m., Resident 106 was observed with urinary catheter drainage bag (a urinary catheter is a thin, flexible tube used to drain urine from the bladder) hanging from his wheelchair and was touching the floor while the occupational therapist (OT) was wheeling him in the hallway outside his room. During a concurrent observation and interview on 5/3/21 at 11:37 a.m., with the OT, she confirmed the above observation and stated that Resident 106's urinary catheter drainage bag should not be touching the floor. During an interview on 5/3/21 at 11:46 a.m. with LVN M, he stated that Resident 106's urinary catheter drainage bag should not be touching the floor when up in his wheelchair due to an infection control issue. 5. Review of Resident 44's admission Record indicated he was admitted to the facility on [DATE] with chronic obstructive pulmonary disease (COPD, a disease that causes airflow blockage and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 18 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 breathing-related problems.) Level of Harm - Minimal harm or potential for actual harm Review of Resident 44's physician order indicated he had an order for ipratropium-albuterol (a solution used to treat air flow blockage and prevent the worsening of COPD) 0.5-2.5 (3) milligram (mg, a metric unit of weight)/3 milliliter (ml, a metric unit of volume) inhale orally via nebulizer (a machine that turns liquid medicine into a fine mist that's inhaled into the lungs; this mist comes through a tube that is attached to a facemask) two times a day related to COPD, dated 8/19/2020. Residents Affected - Many During an observation with licensed vocational nurse C (LVN C) on 5/3/21 at 10:12 a.m., the container bag of Resident 44's nebulizer tubing and facemask was dated 4/18/21. During a concurrent interview with LVN C, she stated the container bag should be changed every week. 6. Review of Resident 112's admission Record indicated she was admitted to the facility on [DATE] with asthma diagnosis (a long-term disease of the lungs, it causes the airways to get inflamed and narrow, and it makes it hard to breathe.) Review of Resident 112's physician order indicated she had orders for budesonide (used to prevent inflammation, swelling, in the lungs, which makes the asthma attack less severe) 0.5 mg/2 ml inhale orally via nebulizer two times a day, dated 4/29/21, and ipratropium-albuterol 0.5-2.5 (3) mg/3 ml inhale orally via nebulizer every 8 hours related to asthma, dated 8/26/2020. During an observation with LVN C on 5/3/21 at 12:17 p.m., Resident 112's nebulizer facemask and tubing were not dated. During a concurrent interview with LVN C, she stated Resident 112's nebulizer facemask and tubing should be dated. Review of the facility's 9/1/13 policy Aerosolized Medication, indicated Change nebulizer set-up weekly. Store medication reservoir, mask and tubing in a clean plastic bag including date supplies were changed. 7. Review Resident 117's admission Record indicated he was admitted to the facility on [DATE] with chronic obstructive pulmonary disease (COPD, a disease that causes airflow blockage and breathing-related problems.) During an observation with LVN C on 5/3/21 at 10:25 a.m., Resident 117 was administered oxygen via nasal cannula (a device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) and the filter of the oxygen concentration was dusty. During a concurrent interview with LVN C, she confirmed the filter of the oxygen concentration was dusty. LVN C stated the filter should be cleaned. Review of the facility's 7/23/18 policy, Oxygen Management, indicated It is the policy of this facility to provide oxygen support in a safe manner. 4. During an initial tour on 5/3/21 at 9:55 a.m., Station 1's Room A, certified nursing assistant F (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 19 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 (CNA F) was picking up dirty linens in room A without wearing a glove on her left hand. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/3/21 at 10:00 a.m., CNA F acknowledged the above observation and stated she removed the glove because it got soiled and did not want to contaminate other linens. CNA F stated she should have put on a new pair of gloves. Residents Affected - Many During an interview with the infection preventionist (IP) on 5/7/21 at 9:25 a.m., he stated CNA F should have put a new pair of gloves after washing her hands. He also stated all the staff were expected to follow the facility's guidelines on donning and doffing of appropriate personal protective equipment (PPE). The facility policy and procedure titled, Standard Precautions dated 10/2018, indicated gloves are worn when handling or touching resident-care equipment that is visibly soiled or potentially contaminated with blood, body fluids, or infectious organisms. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1. Resident 4's nasal cannula (a device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) was touching the floor; 2. Resident 6's nasal cannula was not kept in plastic and was touching the floor; 3. LVN P did not hand sanitize prior and after hand gloving after he wiped his sweat on forehead with a facial tissue; 4. CNA F was not wearing a glove on her left hand while picking up dirty linens in room A; 5. The container bag for Resident 44's nebulizer (a machine that turns liquid medicine into a fine mist that's inhaled into the lungs; this mist comes through a tube that is attached to a facemask) set was not changed; 6. Resident 112's nebulizer set was not dated; 7. The filter of Resident 117's oxygen concentration was dusty; 8. Resident 78's garbage can overflowed; 9. Activity assistant (ACA) removed personal protective equipment (PPE) outside of Resident 78's room and discarded them in the trash can of the medication cart; 10. Resident 106's urinary catheter drainage bag was touching the floor. These failures placed the residents' at increased risk of healthcare-associated infection. Findings: 1. During an observation on 05/03/21 at 09:50 a.m., Resident 4 was sleeping in bed, with oxygen at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 20 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 3 liters via nasal cannula and its tubing was touching the floor. Level of Harm - Minimal harm or potential for actual harm During an interview with LVN M on 5/04/21 at 2:26 p.m., LVN M stated it should not be touching the floor; it should be wrapped or covered with barrier for infection control. Residents Affected - Many 2. During an observation on 05/03/21 at 9:42 a.m., in Resident 6's room, Resident 6's nasal cannula connected to oxygen concentrator was not kept in plastic and was touching the floor. Review of the facility policy and procedure titled, Cleaning of Resident/Client Room and Equipment, medical equipment indicated e. Oxygen and Nebulizer masks and tubing are stored in a clean plastic bag when not in use . 3. During an observation on 5/5/21 at 4:56 p.m., prior to giving eye drop medication to Resident 6, LVN P wiped his sweat on forehead with facial tissue but did not hand sanitize before donning and after doffing gloves. During an interview with LVN P on 5/5/21 at 5:15 p.m., LVN P acknowledged that he should have hand sanitized prior and after hand gloving. Review of the facility policy and procedure titled Hand washing/Hand Hygiene, indicated Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .c. Before preparing or handling medications j. After contact with blood or bodily fluids m. After removing gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 21 of 22 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 055211 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Idylwood Care Center 1002 W. Fremont Avenue Sunnyvale, CA 94087 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to ensure outlet wall plates for two of 12 residents (Residents 8 and 329), were installed in a way to protect residents from potentially dangerous open electrical outlets. Findings: During an observation on 5/03/21 at 11:55 am, Residents 8 and 329's outlet wall plates facing towards the head of the residents bed were broken. During an interview with maintenance supervisor (MS) on 05/04/21 at 3:35 p.m., The MS acknowledged the findings and stated these were not logged in for repair or replacement. During an interview with LVN K on 5/04/21 at 3:45 p.m., LVN K stated if that's were not replaced that can present an electrical shock risk and potential fire hazard to residents' in this room. The facility's undated policy and procedure titled, Maintenance Log Procedure, procedure indicated 1. Fill out the Maintenance Request Form or maintenance log. Clearly state the issue or problem. Also note the urgency (if urgent). 2. Maintenance request form will be checked by Maintenance Dept. on a regular basis to address the stated issue or problem. 3. The status report (verbal or written) will be regularly given back to the one who requested or to the Department Head, until the request has been fulfilled. 4. In case or emergency, maintenance staff is called for immediate repair or replacement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 22 of 22