Health inspection·July 18, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 2's care plan regarding elopement dated 4/28/23 indicated, he had episodes of wandering out of his room and walking into other residents ' room. The facility's intervention includes monitoring Resident 2's whereabouts. Further review of Resident 2's care plan indicated on 5/2/23, Resident 2 had an episode of wandering into other residents' room and found sleeping in other residents' empty bed. During an interview with CNA A on 7/17/23 at 10:52 a.m., CNA A confirmed she witnessed the incident between Resident 1 and Resident 2 on 5/3/23. CNA A stated she saw Resident 2 with his pants and brief down while touching Resident 1's bilateral thigh (front area). Review of Resident 2's Monitoring Tool, dated 5/3/23 indicated, at 8:15 p.m. Resident 2 was wandering and ambulating (walking). During an interview with the nursing supervisor (NS) on 7/17/23 at 12:40 p.m., the NS stated CNA A reported to her the incident between Resident 1 and Resident 2. The NS stated on 5/3/23 at around 8:20 p.m., she saw Resident 2 with his pants and brief down while touching Resident 1's bilateral thigh and immediately separated the residents. During an interview and record review on 7/18/22 at 10:55 a.m., with the minimum data set coordinator (MDSC), the MDSC reviewed Resident 2's MDS dated [DATE] and confirmed Resident 2 had a BIMS score of 1 (severely impaired cognition) and had a behavior of wandering that could significantly intrude other's activities or privacy. The MDSC stated Resident 2 could walk independently across his room where Resident 1's room was located. During a concurrent interview and record review on 7/18/23 at 11:56 a.m., with the social services director (SSD), the SSD reviewed Resident 2's Wandering Assessment, dated 4/26/23, the SSD indicated Resident 2 had a score of 9 (moderate risk for wandering) and on 4/28/23 he had a core of 15 (high risk for wandering). The SSD reviewed her notes dated 4/28/23 and confirmed staff observed Resident 2 had episodes of wandering out of his room and walking into other resident's room. During a concurrent interview and record review on 7/18/23 at 11:18 a.m., with the MDSC, he reviewed Resident 2's clinical record and stated Resident 2's wandering behavior care plan was initiated on 4/26/23 and updated on 4/28/23 had an intervention of monitoring resident's whereabouts. The MDSC confirmed on 5/2/23, Resident 2 had another wandering episode into other residents' room and was found sleeping in other residents' empty beds. There was no new intervention regarding the behavior on 5/2/23. At 11:30 a.m., the MDSC reviewed Resident 2's care plan dated 5/3/23, indicated Resident 2 was seen touching Resident 1's bilateral thighs [front area]. At 11:55 a.m., the MDSC reviewed nurses notes dated 4/28/23 and confirmed Resident 2 had episodes of wandering out of his room and lying in other residents' beds. The MDSC reviewed nurses notes dated 5/3/23 for 5/2/23 indicating Resident 2 had an episode of wandering into other residents room and found sleeping in other residents' empty beds. The MDSC reviewed the CNA's every 15 minutes monitoring tool form 4/26/23 to 5/3/23 and could not provide evidence licensed nurses (LN) monitored Resident 2's whereabouts every shift as indicated in the care plan. During a concurrent interview and record review with the director of nursing (DON) on 7/18/23 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055211 If continuation sheet Page 2 of 3 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 07/18/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 12:18 p.m., the DON reviewed Resident 2's clinical record and confirmed LNs did not have monitoring for Resident 2's whereabouts every shift. The DON stated the LNs started to monitor Resident 2's whereabouts was started on 5/4/23, after the incident on 5/3/23. Review of the facility's policy titled, Policy and Procedure on Elderly and Dependent Adult Abuse/Suspicion of a crime, revised 1/10/2019 indicated, [facility name] culture will not tolerate abuse or neglect of any kind, at any time. It is the policy of this facility to take every proactive measure to prevent the occurrence of alleged abuse to any resident or person served. Each resident and person served has the right to be free from any form of abuse. The policy further indicated, Sexual abuse is non-consensual sexual contact of any type with a resident .It includes, but is not limited to: sexual harassment, sexual coercion, or sexual assault . Event ID: Facility ID: 055211 If continuation sheet Page 3 of 3