Health inspection·December 13, 2023

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview, facility document and policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the facility failed to retransmit Minimum Data Set (MDS) assessments within required timeframes for 8 (Residents #86, #67, #121, #108, #136, #22, #56, and #65) of 29 residents reviewed for MDS requirements. Residents Affected - Some Findings included: A review of a facility policy titled, MDS, Minimum Data Set/Resident Assessment Instrument, effective on 05/27/2015, revealed, It is the policy of this facility to complete the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS) in accordance with the regulations, timeframes and guidelines set forth by OBRA [Omnibus Budget Reconciliation Act]-required and Medicare-required assessments. A review of the CMS Long-Term Care Facility RAI 3.0 User's Manual, version 1.18.11, revised in October 2023, revealed in Chapter 2: Assessments for the RAI that a Significant Correction to a Prior Quarterly (SCQA) must be transmitted no later than the MDS Completion Date + [plus] 14 calendar days, with the MDS Completion Date defined as the 14th day after determination that significant error in prior quarterly assessment occurred. The manual further specified, a Significant Correction to Prior Comprehensive (SCPA) must be transmitted no later than the Care Plan Completion Date + 14 calendar days, with the Care Plan Completion Date defined as the CAA(s) Completion Date [Care Area Assessments, the 14th calendar day after determination that significant error in prior comprehensive assessment occurred] + 7 calendar days. A review of an MDS 3.0 Final Validation Report revealed the following MDS assessments were Rejected on 11/04/2023: - Resident #86's quarterly MDS, with an Assessment Reference Date (ARD) of 10/25/2023; - Resident #67's quarterly MDS, with an ARD of 10/24/2023; - Resident #121's quarterly MDS, with an ARD of 10/26/2023; - Resident #108's annual MDS, with an ARD of 10/24/2023; - Resident #136's quarterly MDS, with an ARD of 10/27/2023; - Resident #22's quarterly MDS, with an ARD of 10/25/2023; (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: 055211 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 12/13/2023 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)