Other·November 5, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a recertification survey conducted on 10/25/2019. The facility was licensed for 48 beds. The census at the time of the survey was 43. The sample size was 12. On 10/22/19 at 11:51 a.m., the survey team called an Immediate Jeopardy with the Administrator related to the dishwasher (see

F812). On 10/23/19 at 11:28 a.m., the survey team abated the Immediate Jeopardy with the Administrator, related to the dishwasher after the team received evidence of an acceptable corrective action plan. For F689, the scope and severity was a "G". Two Class "B" citations were also issued for

F689 and F759. Representing the California Department of Public Health: 39588, Health Facilities Evaluator Nurse; 36623, Health Facilities Evaluator Nurse and 39949, Health Facilities Evaluator Nurse.

F577 SS=C Right to Survey Results/Advocate Agency Info CFR(s): 483.10(g)(10)(11)

F577 11/12/2019 §483.10(g)(10) The resident has the right to(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 1 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies. §483.10(g)(11) The facility must-(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. (ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and (iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. (iv) The facility shall not make available identifying information about complainants or residents. This REQUIREMENT is not met as evidenced by: Based on observation and interview the facility failed to ensure survey results were accessible to eight of eight residents (Residents 34, 12, 10, 14, 4, 11, 1, and 32). This failure had the potential for residents not to be fully informed of facility's performance. Findings: During the initial tour observation on 10/21/19 past survey results was seen pinned on top of a bulletin board more than five feet high. During an interview with the life enrichment specialist on 10/23/19 at 10:26 a.m., he confirmed the survey results were pinned to the top of the bulletin board. He further stated the survey results were too high on the top of the bulletin board and were not accessible to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 2 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents, especially the wheelchair bound residents without assistance.

F640 SS=D Encoding/Transmitting Resident Assessments CFR(s): 483.20(f)(1)-(4)

F640 11/12/2019 §483.20(f) Automated data processing requirement§483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility: (i) Admission assessment. (ii) Annual assessment updates. (iii) Significant change in status assessments. (iv) Quarterly review assessments. (v) A subset of items upon a resident's transfer, reentry, discharge, and death. (vi) Background (face-sheet) information, if there is no admission assessment. §483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. §483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: (i)Admission assessment. (ii) Annual assessment. (iii) Significant change in status assessment. (iv) Significant correction of prior full assessment. (v) Significant correction of prior quarterly FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 3 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assessment. (vi) Quarterly review. (vii) A subset of items upon a resident's transfer, reentry, discharge, and death. (viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment. §483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure minimum data set (MDS, an assessment tool) was transmitted to the Centers for Medicare and Medicaid (CMS, a federal agency) in a timely manner for six out of six sampled residents (3, 6, 4, 5, 1 and 2). This failure put the facility at risk for obtaining quality monitoring data. Findings: During a concurrent review of clinical records and interview with minimum data set nurse (MDSN) on 10/25/19 at 11:48 a.m., the Resident MDS Display indicated the following: 1. Resident 3's last quarterly assessment indicated an actual reference date of 8/25/19 2. Resident 6's last quarterly assessment indicated an actual reference date of 8/19/19 3. Resident 4's last quarterly assessment indicated an actual reference date of 8/2/19 4. Resident 5's last quarterly assessment indicated an actual reference date of 8/25/19 5. Resident 1's last quarterly assessment indicated an actual reference date of 8/19/19 6. Resident 2's last quarterly assessment indicated an actual reference date of 8/19/19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 4 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The MDSN stated above quarterly assessment were not transmitted to CMS. The MDSN also stated quarterly assessment should be transmitted 14 days after the completion date. According to the October 2019 Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 (RAI, MDS Manual), transmission date should be no later than 14 calendar days after the MDS completion date.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 11/12/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 5 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to develop and implement comprehensive person-centered care plans for four of 12 residents (Residents 24, 35 and 15) when: 1. For Resident 24, her fall and skin tear care plan were not implemented; 2. For Resident 35, his bowel regimen was not followed; and 3. For Resident 15, a) no new fall care plan intervention was implemented after fall on 8/5/19, b) Resident 15 was found on the ground in the patio unsupervised on 8/21/19 and c) incontinence care plan was not developed. These failures had the potential to result in the inability to identify the residents' individualized care issues and implement person-centered care. Findings: 1. Review of Resident 24's clinical record indicated she was originally admitted on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 6 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 6/20/15 with diagnoses including dementia (decline in mental capacity affecting daily function) and psychotic disorder (mental disorder affecting sense of reality) with hallucinations (seeing or hearing things that are not real). During an observation on 10/21/19 at 11:09 a.m., Resident 24 was in her room in a geri chair. Resident 24 was fidgeting and moving her arms and legs continuously. The geri chair had padding on top of the arm rests, but did not have padding on the ends of the metal arm rests. The geri chair had cloth covering each of the metal ends of the arm rests. During an interview on 10/21/19 at 11:09 a.m., licensed vocational nurse D (LVN D) stated Resident 24 was always getting new skin tears. During an observation on 10/21/19 at 11:20 a.m., LVN D changed Resident 24's dressings. LVN D removed a geri sleeve (a fabric sleeve placed over skin to protect against damage, e.g. skin tears) from Resident 24's left leg. There were no geri sleeves on her right leg, right arm, or left arm. Resident 24 had multiple wounds on her left lower leg and right lower leg, a wound on her left elbow, and a wound on the top of her right foot. Resident 24 also had bruising along her lower legs. During an interview on 10/21/19 at 11:42 a.m., licensed vocational nurse E (LVN E) stated Resident 24 had skin tears and bruises from the geri chair. During an observation on 10/23/19 at 8:17 a.m., the geri chair was in Resident 24's room. The geri chair did not have padding on the ends of the arm rests. There was a cloth covering the metal end of the right arm rest. The left arm rest did not have a cloth covering FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 7 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the metal end. Review of Resident 24's Plan of Care regarding skin breakdown, indicated she had episodes of restlessness and bumping her legs on the chair causing bruises and skin tears. An intervention indicated, "Pad geri chair as necessary to prevent bumping legs." An intervention, dated 10/5/19, indicated, "Apply geri legs (a geri sleeve for legs) for skin protection due to episodes of restlessness and bumping her legs on the chair." During an observation on 10/24/19 at 9:30 a.m., Resident 24 was up in the geri chair. There was cloth covering the metal ends of the arm rests. The DON removed the cloth. There was approximately four inches of metal on each of the arm rests that did not have padding. During an interview on 10/24/19 at 9:30 a.m., the DON stated there should be padding on Resident 24's geri chair all the time, but it was not there. The DON stated instead of using an appropriate cushion, staff used a thin cloth to cover the metal ends. During an interview on 10/24/19 at 1:27 p.m., the DON stated it is the nursing department's responsibility to put padding on the geri chair. 2. Review of the Resident 35's clinical record indicated he was originally admitted on 10/27/18 with diagnoses including hemiplegia and hemiparesis (muscle weakness or loss of muscle function of one half of the body) and dysphagia (difficulty swallowing). Review of Resident 35's plan of care regarding his bowel and bladder, indicated an intervention: MOM every day as needed for constipation and dulcolax suppository every FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 8 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE other day as needed if MOM ineffective. Review of Resident 35's bowel record from 10/17/19 to 10/23/19, indicated he did not have a bowel movement (BM) for five days from 10/17/19 to 10/21/19. Review of Resident 35's 10/2019 medication administration record (MAR, record of medications given) indicated milk of magnesia (MOM, medication used to relieve constipation) was given on 10/20/19 at 12 p.m. and 10/22/19 at 9 a.m. It indicated dulcolax (medication used to relieve constipation) suppository (administered in the rectum) was given on 10/22/19 at 10 p.m.. During an interview on 10/23/19 at 3:39 p.m., licensed vocational nurse O (LVN O) stated if a resident did not have a BM in a day or two, nurses should give the resident MOM. LVN O stated if the resident still did not have a BM after the MOM, nurses should give a dulcolax suppository. During an interview on 10/24/19 at 8:32 a.m., licensed vocational nurse L (LVN L) stated if a resident does not have a BM for one day, nurses should give MOM. LVN L stated Resident 35 did not have a BM on 10/17/19 so he should have received MOM on 10/18/19. LVN L stated Resident 35 received MOM on 10/20/19, the fourth day of no BM. LVN L confirmed Resident 35 did not get dulcolax on 10/20/19 and stated the next shift should have given a dulcolax suppository because Resident 35 did not have a BM. During an interview on 10/24/19 at 10:14 a.m., the director of nursing (DON) stated nurses should give MOM if a resident has no BM in one day. The DON stated if the resident still has no BM, dulcolax suppository should be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 9 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE given on the next shift. During an interview on 10/25/19 at 7:24 a.m., licensed vocational nurse D (LVN D) stated after one day of no BM, the nurse should give the resident MOM. LVN D stated if the resident still has no BM, the nurse on the next shift should give dulcolax. LVN D confirmed she should have given MOM to Resident 35 on 10/18/19. After reviewing Resident 35's MAR, LVN D stated she gave MOM on 10/20/19 at 12 p.m. LVN D stated the next shift should have given dulcolax on 10/20/19. During a telephone interview on 10/25/19 at 10:26 AM, Resident 35's physician stated Resident 35 should be on a bowel regimen. Resident 35's physician stated she was not informed that Resident 35 did not have a BM. During an interview on 10/25/19 at 11:21 a.m., the DON stated the facility did not have a policy regarding bowel regimen. 3. Review of Resident 15's clinical record indicated she was admitted to the facility on 7/18/17 with diagnoses including dementia, repeated falls, muscle weakness and unsteady gait. During an interview and concurrent record review with the DON on 10/25/19 at 8:13 a.m., she stated Resident 15 has fallen six times from June 2019 to September 2019. a. During an interview with the minimum data set nurse (MDSN) on 10/25/19 at 8:44 a.m., she stated Resident 15 had a witnessed fall on 8/5/19. The MDSN checked Resident 15's clinical record and could not find documentation on new interventions implemented for the fall on 8/5/19. She further stated there should be a resident centered intervention on each fall incident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 10 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE b. During a concurrent interview and record review with the DON on 10/25/19 at 8:40 a.m., she stated Resident 15 had a fall on the outside patio on 8/21/19. This fall was witnessed by a housekeeper. The DON stated the alarms are checked by maintenance and should be on for resident safety. During an interview and record review continued by the MDSN for the DON on 10/25/19 at 8:44 a.m., the MDSC stated Resident 15 wandered around the facility and should not have been outside on the patio by herself. Resident 15 had a WanderGuard (bracelet/alarm system that alerts staff if resident has been away from marked perimeter) on and alarm on the patio door alerts the staff when a resident wanders away from the facility grounds. During an observation and concurrent interview with the maintenance supervisor (MS) on 10/25/19 at 8:58 a.m., he stated wanderguards and door alarm should be on at all times. He opened the patio door and the alarm did not turn on. The MS further stated the door alarm was turned off but it should be on. c. Review of the Resident 15's MDS dated 10/17/19, indicated she was frequently incontinent on both bowel and bladder. During an interview and record review with the MDSN on 10/25/19 at 9:05 a.m., she reviewed Resident 15's care plan and could not find documentation on a care plan for incontinence. The MDSN further stated there should be an incontinence care plan for Resident 15. Review of the facility's policy, "Care Planning", indicated a comprehensive care plan is developed based on the MDS to meet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 11 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE individual needs of the resident, care plan problems include existing difficulties as well as potential problems as identified by the MDS which includes functional status and physical requirements, special treatments, psychosocial status and cognitive status among others.

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 11/11/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on interview on record review, the facility failed to revise the care plan for two of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 12 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12 sampled residents (Resident 24 and Resident 27) when: 1. Resident 24 sustained skin tears from a gerichair and the facility did not add any new interventions to prevent the skin tears. This failure resulted in further skin tears for Resident 24. 2. Resident 27 had a problem of getting up out of her wheelchair unassisted and the facility failed to revise her care plan after identifying a new problem. This failure had the potential to result in injuries for Resident 27. Findings: 1. Review of Resident 24's clinical record indicated she was originally admitted on 6/20/15 with diagnoses including dementia (decline in mental capacity affecting daily function) and psychotic disorder (mental disorder affecting sense of reality) with hallucinations (seeing or hearing things that are not real). During an observation on 10/21/19 at 11:09 a.m., Resident 24 was in her room in a geri chair. Resident 24 was fidgeting and moving her arms and legs continuously. The geri chair had padding on top of the arm rests, but did not have padding on the ends of the arm rests. The geri chair had cloth covering each of the metal ends of the arm rests. During an interview on 10/21/19 at 11:09 a.m., licensed vocational nurse D (LVN D) stated Resident 24 was always getting new skin tears. During an observation on 10/21/19 at 11:20 a.m., LVN D changed Resident 24's dressings. LVN D removed a geri sleeve (a fabric sleeve placed over skin to protect against damage, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 13 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE e.g. skin tears) from Resident 24's left leg. There were no geri sleeves on her right leg, right arm, or left arm. Resident 24 had multiple wounds on her left lower leg and right lower leg, a wound on her left elbow, and a wound on the top of her right foot. Resident 24 also had bruising along her lower legs. During an interview on 10/21/19 at 11:42 a.m., licensed vocational nurse E (LVN E) stated Resident 24 had skin tears and bruises from the geri chair. During an observation on 10/23/19 at 8:17 a.m., the geri chair was in Resident 24's room. The geri chair did not have padding on the ends of the arm rests. There was a cloth covering the metal end of the right arm rest. The left arm rest did not have a cloth covering the metal end. Review of Resident 24's Interdisciplinary Notes, dated 6/3/19, indicated Resident 24 had a skin tear on her left lower leg. The note indicated the CNA reported Resident 24 hit her leg on the side of the geri chair. Review of Resident 24's Interdisciplinary Notes, dated 6/16/19, indicated Resident 24 sustained a skin tear on her left shin while on the geri chair. Review of Resident 24's Interdisciplinary Notes, dated 7/22/19, indicated Resident 24 had a skin tear on her right lower leg. The note indicated Resident 24 was moving her legs up and down. Review of Resident 24's Interdisciplinary Notes, dated 7/26/19, indicated Resident 24 was sitting in the geri chair and moving her legs around. The note indicated Resident 24 had skin tears on both lower legs from the side of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 14 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the recliner chair. Review of Resident 24's Interdisciplinary Notes, dated 8/4/19, indicated Resident 24 hit her leg on the geri chair arm rest and reopened an old skin tear on her left upper leg. Review of Resident 24's Interdisciplinary Notes, dated 8/16/19, indicated Resident 24 was agitated and moving in her geri chair. The note indicated Resident 24 had a skin tear on her left shin. Review of Resident 24's Interdisciplinary Notes, dated 9/20/19, indicated Resident 24 was kicking while in the geri chair. The note indicated Resident 24 hit her left lower leg on the geri chair arm and sustained a skin tear. Review of Resident 24's Interdisciplinary Notes, dated 10/18/19, indicated Resident 24 was sitting in the geri chair and was anxious, kicking, and moving. The note indicated Resident 24 had a self-sustained skin tear on the right dorsal foot. Review of Resident 24's Plan of Care regarding skin breakdown, dated 6/20/15, indicated she had episodes of restlessness and bumping her legs on the chair causing bruises and skin tears. A goal, with a target date of 12/19/19 indicated the resident will have minimal episodes of skin discoloration and skin tears. An undated intervention indicated, "Pad geri chair as necessary to prevent bumping legs." An intervention, dated 10/5/19, indicated, "Apply geri legs (a geri sleeve for legs) for skin protection due to episodes of restlessness and bumping her legs on the chair." During an observation on 10/24/19 at 9:30 a.m., Resident 24 was up in the geri chair. There was cloth covering the metal ends of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 15 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE arm rests. The DON removed the cloth. There was approximately four inches of metal on each of the arm rests that did not have padding. During an interview on 10/24/19 at 9:30 a.m., the DON stated there should be padding on Resident 24's geri chair all the time, but it was not there. The DON stated instead of using an appropriate cushion, staff used a thin cloth to cover the metal ends. During an interview on 10/24/19 at 1:27 p.m., the DON stated it is the nursing department's responsibility to put padding on the geri chair. The DON stated she would find out when Resident 24's care plan regarding skin breakdown was evaluated for effectiveness. During an interview on 10/25/19 at 9:10 a.m., the DON stated she would get Resident 24's care plan to show when it was revised or evaluated. No documentation was provided that indicated Resident 24's care plan regarding skin breakdown was revised to prevent the recurring skin tears. 2. During a review of the clinical records for Resident 27, the Physician's Order report dated from 10/1/19 to 10/31/19, indicated Resident 27 was admitted on 9/19/17 with diagnoses of Parkinson's disease (a chronic and progressive movement disorder) and difficulty in walking. During a review of the clinical record for Resident 27, the plan of care dated 10/1/19 indicated under "problem" column "episode getting up from wheelchair unassisted" with no new intervention. During an interview with the director of nursing (DON) on 10/25/19 at 1:11 p.m., the DON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 16 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE confirmed there was no new intervention related to identified problem from Resident 27. The DON also stated there was no documented evidence related to the cause why Resident 27 got up from wheelchair unassisted. A review of the facility's policy, "Care Planning" dated 2/18, indicated "7. Assessing and evaluating the Care Plan. When evaluating and reassing the plan of care for the resident the following shall be considered" a. Are the resident's problem still current? Are there new problems? b. Are the action/approaches appropriate and effective? c. Are the objectives being met within designated time frames? d. Are all appropriate member of the interdisciplinary team involved in the plan of care as needed?"

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 11/12/2019 SS=D CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 17 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of 12 residents (Resident 140) when the facility did not provide an Alternating Pressure Mattress (APP mattress, mattress pad with bubble like cells that alternate pressure to reduce pressure point for Resident 140. Resident 140 developed a stage 2 pressure ulcer on her coccyx. Findings: Review of Resident 140's clinical record indicated she was admitted to the facility on 9/16/19 with diagnoses including compression fractures of the spine, abnormalities of gait and acute kidney failure. Her minimum data set (MDS, an assessment tool) on 9/30/19 and 10/7/19 indicated her skin was intact and pressure reducing devices were not used for Resident 140. Review of Resident 140's "Pressure Sore Risk" assessment dated 9/16/19, indicated she was high risk to acquire pressure ulcer. Review of Resident 140's interdisciplinary team (IDT) notes on 9/18/19, did not address Resident 140's high risk for pressure ulcer development. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 18 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 140's at risk for skin breakdown care plan initiated on 9/16/19 and licensed nurse (LN) weekly summary notes dated 9/22/19, 9/29/19, and 10/6/19, did not indicate the use of pressure reducing devices. Review of Resident 140's LN weekly summary notes dated 10/13/19, indicated a stage two pressure injury/ulcer developed on her coccyx. During an interview and record review with licensed vocational nurse J (LVN J) on 10/23/19 at 4:02 p.m., she stated Resident 140 had a facility acquired stage 2 pressure ulcer on her coccyx. The pressure ulcer was first noted on 10/13/19. The pressure ulcer measured 1.8 cm x1.2 cm x 0.1 cm (cm, centimeters, a unit of measurement) on 10/13/19. During an interview with the director of staff development (DSD) on 10/23/19 at 4:47 p.m., she stated residents with high risk for pressure ulcers should have an APP mattress, skin monitoring and be repositioned every two hours. During an interview with the director of nursing (DON) on 10/23/19 at 4:56 p.m., she confirmed Resident 140 was at high risk to develop pressure ulcers on admission and should have an APP mattress upon admission on 9/16/19. Further, she confirmed the IDT did not address Resident's 140 high risk for pressure ulcer development on the meeting on 9/18/19. The DON reviewed Resident 140's clinical records was unable to find evidence of using a pressure reducing device with Resident 140 upon identifying her high risk for developing pressure ulcer. Review of the facility's policy, "Skin Preventative Methods", dated 8/16, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 19 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident assessed to be at risk for skin impairment will have preventative measures placed into effect as appropriate for the resident to prevent skin breakdown.

F688 SS=D Increase/Prevent Decrease in ROM/Mobility CFR(s): 483.25(c)(1)-(3)

F688 11/12/2019 §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure one of 12 residents (Resident 2) received restorative nursing exercises per physician orders. This failure had the potential to decrease resident's range of motion (ROM, full movement potential of a joint). Findings: Review of Resident 2's clinical record indicated she was admitted to the facility with diagnoses including Parkinson's disease (disorder of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 20 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE central nervous system that affects movement, often including tremors) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of Resident 2's physician order indicated restorative ambulation five times a week. Review of Resident 2's restorative nursing record for July 2019 and August 2019 indicated Resident 2 was not ambulated on 7/5/19, 7/19/19, 7/22/19 and 8/19/19 as scheduled and as ordered. During an interview and concurrent record review with the director of nursing (DON) on 10/25/19 11:09 a.m., she stated Resident 2 should be ambulated five times per week as ordered. She confirmed the above record review of missed ambulation. Review of the facility's policy, "Restorative Nursing Program", indicated the RNA (restorative nursing assistant) is responsible for providing care (daily) as per the physician order.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 11/12/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 21 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, and record review, the facility failed to prevent accidents for one of six residents (Resident 24) when staff did not: 1. Implement an intervention for a wheelchair evaluation and provide adequate supervision to prevent Resident 24's falls, which resulted in a right femur neck fracture (right hip fracture), hospitalization, and surgery; and 2. Eliminate hazards when Resident 24's geriatric chair (geri chair, a large chair with wheels that can recline) was not fully padded at the metal ends of the arm rest, which resulted in repeated skin tears and bruising. Findings: 1. Review of Resident 24's clinical record indicated she was originally admitted on 6/20/15 with diagnoses including dementia (decline in mental capacity affecting daily function) and psychotic disorder (mental disorder affecting sense of reality) with hallucinations (seeing or hearing things that are not real). Resident 24 was under hospice care from 8/29/18 to 8/30/19. Review of Resident 24's Fall Risk, dated 3/4/19 indicated she was at risk for falls. Review of Resident 24's minimum data set (MDS, an assessment tool), dated 3/8/19, indicated her cognition was severely impaired. Resident 24 required extensive assistance with one person for transfers and total dependence for locomotion. Review of Resident 24's Interdisciplinary Notes, dated 2/15/19, indicated she had an unwitnessed fall on 2/13/19 when she was found seated on the hallway floor near her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 22 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE room. The note indicated Resident 24 believed she can transfer by herself. Review of Resident 24's Interdisciplinary Notes, dated 3/22/19, indicated she was found lying on the floor close to the dining table. The note indicated activity staff saw Resident 24 try to wheel herself out of the dining room. The note also indicated after the activity staff placed her in front of a dining table, the staff saw Resident 24 lean to the left and slowly fell out of the chair. Review of Resident 24's Plan of Care regarding fall risk, indicated an intervention, dated 3/25/19, "When in activities have Resident 24 close to activity staff for safety." Review of Resident 24's Interdisciplinary Notes, dated 4/12/19, indicated she ate lunch in the dining room at 12:20 p.m. The note indicated at 12:25 p.m., Resident 24 was sitting down on top of the foot rests of the wheelchair and the wheelchair was on top of her. Resident 24 sustained a skin tear on her right lower leg and a skin tear on her left lower leg. Review of Resident 24's Interdisciplinary Notes, dated 4/15/19, indicated the current intervention for Resident 24 was no foot rests and request hospice to evaluate for the proper wheelchair. Review of Resident 24's Plan of Care regarding fall risk, indicated an intervention, dated 4/15/19, "During meals, have Resident 24 seated at the first table in the dining room with staff at her side." There was no intervention in Resident 24's care plan that addressed how Resident 24 would be supervised after activities, or after meals, or when Resident 24 would wheel herself in the dining room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 23 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 24's Interdisciplinary Notes, dated 4/30/19, indicated on 4/29/19 at 5:45 p.m., a certified nursing assistant (CNA) found Resident 24 on the floor in the dining room while the CNA was assisting another resident to eat. The note also indicated Resident 24 complained of right leg pain. Review of Resident 24's Radiology Report, dated 4/30/19, indicated acute displaced right femoral neck fracture. Review of Resident 24's Interfacility Transfer record from the hospital, dated 5/5/19, indicated Resident 24 had a hip fracture and bipolar hemiarthroplasty (type of surgery to repair a fracture) of the right hip. During an interview on 10/23/19 at 3:35 p.m., the minimum data set nurse (MDSN) stated she had to "keep digging" to find Resident 24's hospice evaluation for the proper wheelchair. During an interview on 10/24/19 at 8:59 a.m., the director of nursing (DON) stated Resident 24 was impulsive so she was placed in the front during activities or beside staff and within reach of staff. The DON stated the plan was for staff to be close to Resident 24, and if Resident 24 started to wheel herself around, staff should walk with her and ask her what she wanted. The DON confirmed the plan to walk with Resident 24 when she started to wheel herself was not put in writing in Resident 24's care plan. The DON stated when Resident 24 fell on 4/29/19, staff was there to witness the fall but was not close enough to intercept her. The DON stated she would look for documentation regarding hospice evaluation of Resident 24's wheelchair or any evaluation of Resident 24's wheelchair done by the facility's rehabilitation (rehab) department. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 24 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 10/24/19 at 12:52 p.m., the director of rehab stated the rehab department did not evaluate Resident 24's wheelchair. No documentation was provided that indicated Resident 24 had her wheelchair evaluated by hospice or by the facility. Review of the facility's policy, "FALL PREVENTION PROGRAM," revised 2/2016, indicated the interdisciplinary team should provide adequate interventions to minimize risk for falling and then evaluate the effectiveness of those interventions. The policy also indicated the nursing function of the program is to identify causative factors should a fall occur, and then accelerate the care plan with new interventions to prevent further falls. 2. During an observation on 10/21/19 at 11:09 a.m., Resident 24 was in her room in a geri chair. Resident 24 was fidgeting and moving her arms and legs continuously. The geri chair had padding on top of the arm rests, but did not have padding on the ends of the arm rests. The geri chair had cloth covering each of the metal ends of the arm rests. During an interview on 10/21/19 at 11:09 a.m., licensed vocational nurse D (LVN D) stated Resident 24 was always getting new skin tears. During an observation on 10/21/19 at 11:20 a.m., LVN D changed Resident 24's dressings. LVN D removed a geri sleeve (a fabric sleeve placed over skin to protect against damage, e.g. skin tears) from Resident 24's left leg. There were no geri sleeves on her right leg, right arm, or left arm. Resident 24 had multiple wounds on her left lower leg and right lower leg, a wound on her left elbow, and a wound on the top of her right foot. Resident 24 also had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 25 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE bruising along her lower legs. During an observation on 10/21/19 at 11:42 a.m., Resident 24 was continuously moving her left leg. Resident 24's left leg kept getting trapped in between the foot rest and the side of the chair and needed help to remove it. During an interview on 10/21/19 at 11:42 a.m., licensed vocational nurse E (LVN E) stated Resident 24 had skin tears and bruises from the geri chair. LVN E stated Resident 24 usually had a pillow under her legs to prevent her legs from getting stuck between the foot rest and the side of the chair. During an observation on 10/23/19 at 8:17 a.m., the geri chair was in Resident 24's room. The geri chair did not have padding on the ends of the arm rests. There was a cloth covering the metal end of the right arm rest. The left arm rest did not have a cloth covering the metal end. Review of Resident 24's Interdisciplinary Notes, dated 6/3/19, indicated Resident 24 had a skin tear on her left lower leg. The note indicated the CNA reported Resident 24 hit her leg on the side of the geri chair. Review of Resident 24's Interdisciplinary Notes, dated 6/16/19, indicated Resident 24 sustained a 4 centimeters (cm, unit of measurement; 4 cm equals about 1.5 inches) by 4 cm skin tear on her left shin while on the geri chair. Review of Resident 24's Interdisciplinary Notes, dated 7/22/19 indicated Resident 24 had a skin tear on her right lower leg. The note indicated Resident 24 was moving her legs up and down. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 26 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 24's Interdisciplinary Notes, dated 7/26/19, indicated Resident 24 was sitting in the geri chair and moving her legs around. The note indicated Resident 24 had skin tears on both lower legs from the side of the recliner chair. Review of Resident 24's Interdisciplinary Notes, dated 8/4/19, indicated Resident 24 hit her leg on the geri chair arm rest and reopened an old skin tear on her left upper leg. Review of Resident 24's Interdisciplinary Notes, dated 8/16/19, indicated Resident 24 was agitated and moving in her geri chair. The note indicated Resident 24 had a skin tear on her left shin. Review of Resident 24's Interdisciplinary Notes, dated 9/20/19, indicated Resident 24 was kicking while in the geri chair. The note indicated Resident 24 hit her left lower leg on the geri chair arm and sustained a skin tear. Review of Resident 24's Interdisciplinary Notes, dated 10/18/19, indicated Resident 24 was sitting in the geri chair and was anxious, kicking, and moving. The note indicated Resident 24 had a self-sustained skin tear on the right dorsal foot. Review of Resident 24's Plan of Care regarding skin breakdown, indicated she had episodes of restlessness and bumping her legs on the chair causing bruises and skin tears. An intervention indicated, "Pad geri chair as necessary to prevent bumping legs." An intervention, dated 10/5/19, indicated, "Apply geri legs (a geri sleeve for legs) for skin protection due to episodes of restlessness and bumping her legs on the chair." During an observation on 10/24/19 at 9:30 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 27 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a.m., Resident 24 was up in the geri chair. There was cloth covering the metal ends of the arm rests. The DON removed the cloth. There was approximately four inches of metal on each of the arm rests that did not have padding. During an interview on 10/24/19 at 9:30 a.m., the DON stated there should be padding on Resident 24's geri chair all the time, but it was not there. The DON stated instead of using an appropriate cushion, staff used a thin cloth to cover the metal ends. During an interview on 10/24/19 at 1:27 p.m., the DON stated it is the nursing department's responsibility to put padding on the geri chair. During an interview on 10/25/19 at 8:21 a.m., certified nursing assistant M (CNA M) stated Resident 24 hit her legs against the side of the geri chair. CNA M stated we usually put a pillow under her legs and use socks on the arm rests. Review of the facility's policy, "SKIN CARE PREVENTATIVE METHODS," revised 8/2016, indicated residents assessed to be at risk for skin impairment will have preventative measures placed into effect as appropriate for the resident to prevent skin breakdown. The policy also indicated to avoid skin injury: pad side rails, wheelchair arms, wheelchair foot rests; and use arm or leg protectors, geri sleeves.

F692 SS=D Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 11/12/2019 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 28 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to communicate the recommendations from registered dieticians (RD) to the physician timely for one of five residents (Resident 8). This failure had the potential to result in the resident's weight loss. Findings: Review of Resident 8's clinical record indicated she was originally admitted on 5/12/18 with diagnoses including hemiplegia and hemiparesis (muscle weakness or loss of muscle function of one half of the body) and dysphagia (difficulty swallowing). Review of Resident 8's physician order, dated 12/24/18, indicated to provide a health shake twice a day by mouth as a supplement. Review of Resident 8's Interdisciplinary Notes, dated 4/4/19, from the former RD (FRD) indicated she recommended to add health shake three times a day to help prevent further FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 29 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE weight loss. Review of the FRD's log (communication to nurses), dated 4/4/19, indicated her recommendation to add health shake three times a day was not included under interventions for Resident 8. Review of Resident 8's Nutritional Assessment, dated 10/2/19, from the RD indicated she recommended to increase health shakes to three times a day to help meet the resident's needs. Review of the RD's communication to nurses dated 10/2/19, indicated she had a recommendation for Resident 8 to increase health shakes to three times a day. During an interview on 10/23/19 at 12 p.m., the RD stated on 10/2/19 she recommended to change Resident 8's health shakes from two times a day to three times a day. The RD stated she gave the recommendations to the nurses and the nurses should communicate the recommendations to the physician. The RD confirmed the FRD also recommended to increase the health shakes to three times a day. The RD confirmed the recommendations were not followed-up and Resident 8 was still getting health shakes two times a day. During an interview on 10/24/19 at 2:02 p.m., the director of nursing (DON) confirmed the FRD's recommendations on 4/4/19 was not included in the communication to nurses. The DON stated the physician did not receive the RD's recommendation until 10/23/19. During an interview on 10/25/19 at 9:14 a.m., the DON stated she could not find documentation that indicated the physician was notified of the RD's recommendations before FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 30 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10/23/19. During an interview on 10/25/19 at 11:22 a.m., the DON stated it is the RD's responsibility to communicate their recommendations to the nurses and to follow-up on their recommendations. Review of Resident 8's 10/2019 medication administration record (MAR, record of medications given) indicated Resident 8 was receiving health shakes two times a day until 10/23/19. Review of the facility's policy, "Registered Dietitian Recommendations," dated 8/18/08, indicated a copy of the RD recommendations will be given to the DON and the DON or designated nursing staff will call the physician. The policy indicated nursing will follow up on all RD recommendations within 72 hours or less. The policy also indicated if there has been no follow-up within 72 hours, the RD will send an email alerting the DON for immediate action.

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 11/12/2019 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 31 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review, the facility failed to ensure the physician's order for oxygen therapy was followed for one of 12 residents (Resident 6) when Resident 6 did not receive the oxygen litres per minutes (LPM) as ordered. These failures had the potential to affect the safety and respiratory well-being of Resident 6. Findings: Review of Resident 6's clinical record indicated she was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During an observation on 10/21/19 at 10:05 a.m., Resident 6's oxygen concentrator was set to 3 LPM. During an observation on 10/23/19 at 8:43 a.m., Resident 6's oxygen was set to 3 LPM. During an observation and concurrent interview with the licensed vocational nurse E (LVN E) on 10/23/19 at 8:50 a.m., she confirmed oxygen was set on 3 LPM. She further stated the physician's order was 2 LPM, the oxygen should be set at 2 LPM. Review of facility's policy, "Oxygen Therapy", indicated oxygen therapy is administered by a licensed nurse as ordered by the physician.

F732 SS=C Posted Nurse Staffing Information CFR(s): 483.35(g)(1)-(4)

F732 10/25/2019 §483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 32 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. §483.35(g)(2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. §483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. §483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility did not ensure that its staffing information was in a prominent place accessible to residents and visitors; and included the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. This deficient practice had the potential not having information for residents and visitors on the number of nurses, who were available to care for their needs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 33 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: During an observation at the nurse's station on 10/21/19 at 7:58 a.m., there was no staff information posted in a prominent place accessible to resident and visitors. During an observation at the nurse's station on 10/22/19 at 9:50 a.m., there was no staff information posted in a prominent place accessible to resident and visitors. During an observation at the nurse's station on 10/23/19 at 3:52 p.m., there was no staff information posted in a prominent place accessible to resident and visitors. During an interview with the director of nursing (DON) on 10/23/19 at 3:54 p.m., the DON confirmed the staffing information was not posted in a prominent place accessible to residents and visitors.

F757 SS=D Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 11/12/2019 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 34 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure one of 12 residents (Resident 9) was free from unnecessary medications when Resident 9 did not receive monitoring for bruising related to the use of anticoagulant treatment (blood thinning medication to prevent blood clots or stroke). This failure had the potential for side effects to go undetected and not intervened timely. Findings: Review of Resident 9's clinical record indicated she was admitted to the facility on 6/27/19 with diagnoses including atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow.), dementia (a group of thinking and social symptoms that interferes with daily functioning and end stage heart failure. Review of Resident 9's physician's order indicated to take Coumadin (an anticoagulant) 0.5 milligrams (mg, a unit of measurement) daily at bed time. Review of Resident 9's care plan initiated on 6/27/19 related to at risk for bleeding or bruising related to Coumadin use indicated, to monitor for and documented signs and symptoms of untoward bleeding, for example increased bruising. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 35 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview and concurrent record review with licensed vocational nurse E (LVN E) on 10/23/19 at 2:11 p.m., she stated residents taking anticoagulants are monitored for bleeding and bruising. Resident 9 has several bruises in her arms and hands due to blood draws. LVN E reviewed Resident 9's care plan and stated licensed nurses were aware of the bruises on her arms. However, the nurses were not monitoring the bruises for size and color. Further, LVN E stated the bruises should be monitored if they improved or not. During an observation and interview with the director of nursing (DON) on 10/24/19 at 4:23 p.m., she confirmed Resident 9 had a bruise on her left hand and the size of the bruise should be monitored. Review of facility's policy, "Care Planning", indicated initial care plan will be developed and implemented and will include interventions to provide effective and person-centered care that meets professional standards of quality of care.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 11/12/2019 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 36 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: During a review of the clinical records for Resident 27, the Physician's Order report dated from 10/1/19 to 10/31/19, indicated Resident 27 was admitted on 9/19/17 with diagnoses of Parkinson's disease (a chronic and progressive movement disorder) and difficulty in walking. During a review of the clinical records for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 37 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 27, the Physician's Order report dated from 10/1/19 to 10/31/19, indicated an order on 3/20/18 at Xanax (is used to treat anxiety and panic disorders) take 0.25 mg (milligrams, a unit of measurement) one tablet by mouth daily after lunch for panic attack. During a review of the clinical records for Resident 27, the Medication Records dated 9/2019 indicated a behavior monitoring to monitor for episodes of increased panic attacks every shift. During an interview with licensed vocation nurse L (LVN L) on 10/25/19 at 8:22 a.m., LVN L stated Resident 27's manifestation of panic attack was when Resident 27 verbalized, "I'm having a panic attack." During an interview with licensed vocational nurse M (LVN M) on 10/25/19 at 8:30 a.m., LVN M stated Resident 27's manifestation of panic attack was when Resident 27 would suddenly become afraid and she wanted to go somewhere. A review of the facility's policy, "Psychotherapeutic Medication Use", dated 2/14, indicated the resident should only be given medication if clinically indicated and as necessary to treat a specific condition and target symptoms as diagnosed and documented in the records. Based on interviews and record reviews, the facility failed to ensure three of 12 residents (Resident 141, 15 and 27) were free from psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when: 1. For Resident 141, Seroquel (an antipsychotic medication) was increased without appropriate clinical rationale; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 38 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. For Resident 27, side effects were not adequately monitored for four psychotropic medications (Remeron for depressive mood, Depakote sprinkles for dementia with behavioral disturbance, Ativan for anxiety and Zyprexa for bipolar disorder [mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs]); and 3. For Resident 15, target behavior was not specific based on the symptoms that Resident 27 was exhibiting. These failures had the potential for the residents to have medication side effects and behavior unmonitored and reports and receive unnecessary medication. Findings: 1. Review of Resident 141's clinical record indicated he was re-admitted to the facility on 9/5/19 for diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors) Review of Resident 141's physician's orders dated 9/5/19, indicated give Seroquel 25 mg for psychosis related to stage of Parkinson's disease manifested by visual-audio hallucinations causing distress. Review of Resident 141's neurology consult notes dated 10/3/19, indicated to start Nuplazid (an antipsychotic medication) which takes effect in 4-6 weeks at which time can slowly decrease in Seroquel Review of Resident 141's physician orders dated 10/20/19, indicated add Seroquel 12.5 mg by mouth at 4:00 p.m. for visual-audio hallucinations causing distress and paranoia. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 39 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 141's behavior monitoring from August 2019 to October 2019, indicated three episodes of hallucinations in August 2019. During an interview with licensed vocational nurse P (LVN P) on 10/24/19 at 2:40 p.m., she stated per the family member's request to Resident 141's neurologist, Seroquel was increased by 12.5mg per day on 10/20/19. Further, LVN P stated Resident 141 did not exhibit increased episodes of hallucinations and staff did not see the behavior manifested. Review of facility's policy on psychotherapeutic medication use indicated, the resident should only be given medication if clinically indicated; residents must receive gradual dose reductions; the lowest, effective dose shall be used in a way that promotes the resident's highest practicable physical, mental and psychosocial well-being. 2. Review of Resident 15's physician's orders indicated Resident 15 takes for psychotropic medications: Remeron 15 mg once a day for depressive mood, Depakote sprinkles 375 mg twice a day for dementia with behavioral symptoms manifested by impulsive behavior, Ativan 0.25 mg twice a day for anxiety manifested by undirectable yelling, kicking and screaming, and Zyprexa 2.5 mg twice a day fir bipolar disorder with psychotic episodes manifested by yelling, restlessness and combativeness. During an interview with registered nurse K (RN K) on 10/24/19 at 4:00 p.m., she confirmed Resident 15 was taking the above-mentioned medications. Furhter, RN K stated Resident 15 was being monitored for side effects of the psychotropic medications. However, RN K could not articulate the side effects of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 40 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medications being monitored. During an interview with the the director of nursing (DON) on 10/24/19 at 4:12 p.m., she stated the licensed nurses should know the side effects of the medications they administer to the residents. Review of the facility's policy, "Psychotherapeutic Medication Use", indicated possible side effects will be monitored in the medication administration record. Facility's registered nurse essential functions include to coordinate and perform patient assessment and plan of care evaluation.

F759 SS=D Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 11/12/2019 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility had a 16% medication error rate when four medication errors occurred out of 25 opportunities during the medication observations for four out of six residents (10, 191, 35 and 30); 1. For Resident 10, a medication was administered without a physician's order. 2. For Resident 191, an insulin was not timely given. 3. For Resident 35, controlled released medication was crushed and administered. 4. For Resident 30, a topical patch was administered on top of a hairy area. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 41 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE These failures had the potential to compromise the residents' medical health and safety. Findings: 1. For Resident 10, a medication was administered without a physician's order. During a review of the clinical record for Resident 10, the physician's order dated 10/1/19 to 10/31/19 indicated Resident 10 was admitted on 6/30/18 with diagnoses of muscle weakness and high blood pressure. During a medication pass observation with licensed vocational nurse D (LVN D) on 10/21/19 at 9:09 a.m., LVN D administered one drop of artificial tears (used for dryness of the eyes) on Resident 10's both eyes. During a concurrent record review and interview with LVN E on 10/21/19 at 10:52 a.m., LVN E there was not current order to administer artificial tears for Resident 10 because it was already discontinued since 9/27/19. LVN E confirmed LVN D can't administer the medication without a physician's order. During an interview with the director of nursing (DON) on 10/23/19 at 9:22 a.m., the DON stated licensed nurses were not supposed to administer medications without a physician's order. A review of the facility's policy dated 9/18, "Medication Administration General Guidelines", indicated "medications are administered in accordance with written orders of the prescribers." 2. For Resident 191, an insulin was not timely given. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 42 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of the clinical record for Resident 191, the face sheet updated 10/3/19 indicated, Resident 191 was admitted on 9/29/19 with diagnoses of type 1 diabetes (a chronic condition where the pancreas produces little to no insulin to regulate blood sugar). During a medication pass observation with LVN D on 10/21/19 at 12:20 p.m., LVN D checked Resident 191's blood sugar using a glucometer (a medical device for determining the approximate concentration of glucose (sugar) in the blood). LVN D stated current blood sugar was at 233. During a concurrent observation and interview with Resident 191 on 10/21/19 at 12:24 p.m., Resident 191 was observed in-front of his lunch tray. Resident 191 stated he just finished his lunch. During an observation with LVN D on 10/21/19 at 12:37 p.m., LVN D administered seven units of Novolog (used to improve blood sugar control) subcutaneously (between the skin and muscle) to Residents 191 abdomen. During an interview with LVN D on 10/21/19 at 12:40 p.m., LVN D stated Resident 191's Novolog order was to give before meals. LVN D stated Novolog was a fast-acting insulin and lunch starts at 11:30 a.m. During a review of the clinical record for Resident 191, the physician's order dated 9/29/19 indicated, Novolog Insulin Aspart U-100 injection 0-5 units three times a day before meals subcutaneously. During an interview with the DON on 10/23/19 at 9:22 a.m., the DON stated Resident 191's Novolog should be given before meals. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 43 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's policy dated 9/18, "Medication Administration General Guidelines", indicated "medication to be given on an empty stomach or before meals are to be scheduled for administration 30 minutes to 2 hours prior to meals." 3. For Resident 35, controlled released medication was crushed and administered. During a review of the clinical record for Resident 35, the face sheet updated 10/24/19 indicated, Resident was admitted on 10/27/18 with diagnoses of hemiplegia (paralysis of either the left or right side of the body), hemiparesis (weakness of either the left or right side of the body), muscle weakness and difficulty swallowing. During a medication pass observation with registered nurse K (RN K) on 10/21/19 at 4:02 p.m., RN K was observed crushing Carbidopa/Levadopa (used to treat symptoms of Parkinson's Disease (a chronic and progressive movement disorder) ER (extended release) 25/100 ER tab for Resident 35. During a medication pass observation with RN K on 10/21/19 at 4:22 p.m., RN K administered crushed Carbidopa/Levadopa ER 25/100 tab via GT (gastrostomy tube, is the creation of an artificial opening into the stomach) to Resident 35. During a concurrent observation and interview with RN K on 10/21/19 at 4:23 p.m., RN K confirmed she crushed Resident 35's Carbidopa/Levadopa ER 25/100 tab and administered it via GT. RN K stated pharmacy label affixed to the medication bubble pack indicated Carbidopa/Levadopa ER 25/100 tab and it also indicated "Do not chew or crushed." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 44 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE RN K stated there was another Carbidopa/Levadopa 25/100 tab inside the medication cart with no indication to not crushed or chew. RN K confirmed she should have not crushed Carbidopa/Levadopa ER 25/100 if there was a variation of the same drug that was crushable. A review of the facility's policy dated 9/18, "Medication Administration General Guidelines", indicated "Long-acting or entericcoated dosage forms should generally not be crushed; an alternative should be sought." 4. For Resident 30, a topical patch was administered on top of a hairy area. During a review of the clinical record for Resident 30, the face sheet updated 10/22/19 indicated, Resident 30 was admitted on 9/5/19 with diagnoses of atherosclerosis (narrowing of the arteries) and cataract (a condition affecting the eye that causes clouding of the lens). During a medication pass observation with LVN K on 10/22/19 at 7:51 a.m., LVN K administered Lidocaine Topical Relief Patch (used for pain) on Resident 30's upper back extending to the upper nape (is the back of the neck) containing hair. During an interview with LVN K on 10/22/19 at 7:55 a.m., LVN K confirmed she administered the patch on Resident 30's upper back extending to the upper nape containing hair. LVN K stated Resident 30 will not properly absorb the medication if it was administered on a hairy area. During a review of the clinical record for Resident 30, the physician's order dated 9/5/19 indicated, Lidocaine 4% patch, apply 1 patch daily, on for 12 hours and off for 12 hours, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 45 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE apply on neck and nape area. During an interview with the DON on 10/23/19 at 9:22 a.m., the DON stated topical patches should not be applied on a hairy area. A review of the facility's policy dated 5/16, "Transdermal Delivery System (Patches)", indicated to avoid extremities and hairy body areas.

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 11/12/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 46 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to store and labeled medications based on facility policy when: 1. A bottle of eye drops was stored passed the manufacturer's guideline. 2. Two vials of insulins were undated. These failures could potentially compromise the health and safety of the residents. Findings: 1. A bottle of eye drops was stored passed the manufacturer's guideline. During a medication cart audit with licensed vocational nurse M (LVN M) on 10/21/19 at 10:00 a.m., a bottle of latanoprost was opened and dated 9/8/19. LVN M stated latanoprost was only good until 42 days after opening. During an interview with the director of nursing (DON) on 10/23/19 at 9:28 a.m., the DON confirmed Latanoprost was only good for 42 days after opening. According to the manufacturer's specification for Latanoprost, once a bottle is opened for use, it may be stored at room temperature for six weeks. A review of the facility's policy dated 9/18, "Medication Storage", indicated outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock and disposed of according to procedures for medication disposal. 2. Two vials of insulins were undated. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 47 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a medication cart audit with LVN M on 10/21/19 at 10:00 a.m., two vials of insulins were undated. LVN M confirmed two insulins vials are undated when it was opened. LVN M also added insulin vials were only good for 28 days after opening. During an interview with the DON on 10/23/19 at 9:28 a.m., the DON stated insulin vials should be labeled with date when they were opened. A review of the facility's policy dated 9/18, "Medication Storage", indicated insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used.

F801 SS=D Qualified Dietary Staff CFR(s): 483.60(a)(1)(2)

F801 11/11/2019 §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e) This includes: §483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 48 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose. (ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional. (iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section. (iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law. §483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who(i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a national certifying body; or D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 49 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE restaurant management, from an accredited institution of higher learning; and (ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and (iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure the director of dining services (DDS) effectively evaluated services operations in accordance of his job description. Failure to ensure effective oversight of day to day dietetic services operation had the potential to result in putting 43 out of 43 residents who received food from the kitchen at nutritional risk, in turn further compromising the medical status of residents. Findings: A review of the undated facility job description for the DDS indicated, the DDS follows highest standard of cleanliness, federal, state, corporate policies, health codes and guidelines in preparation of food. The job description further indicated, the DDS has supervisory responsibilities in accordance with the organization's policies and applicable laws include managing subordinate supervisors who supervise employees in the dining room and dining services department; responsible for the overall direction, coordination, and evaluation of these units. Observation and interviews in the kitchen over the course of the survey from 10/21/19 to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 50 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10/25/19, showed there were multiple issues surrounding the delivery of Food and Nutrition Services (cross reference, F812) in relationship to dish washing temperature based on the requirements of the manufacturer and facility policy. During an interview with the Ecolab (an American global provider of water, hygiene and energy technologies and services to the food, energy, healthcare, industrial and hospitality markets) technician (ET) with the presence of the director of dining services (DDS) on 10/22/19 at 10:33 a.m., the ET stated dishwashing machine final rinse temperature does not have to reach 120 F as long as the chlorine chemical sanitizer was at 50 PPM (parts per million, a unit of measurement). The ET confirmed dishwashing was a low temperature machine and uses chemical chlorine to sanitize. During an interview with the DDS on 10/22/19 at 10:05 a.m., the DDS confirmed what the ET stated. The DDS reiterated dishwashing machine don't need to reach a temperature of 120 F (Fahrenheit, a unit of measurement) during final rinse if the sanitizing chemical reaches at 50 PPM. During an interview with the registered dietician (RD) on 10/23/19 at 10:26 a.m., the RD stated she only worked at the facility on a part-time basis. The RD stated the DDS had an obligation to know the requirements for the dish washing machine and to fix the problem right away.

F802 SS=D Sufficient Dietary Support Personnel CFR(s): 483.60(a)(3)(b) FORM CMS-2567(02-99) Previous Versions Obsolete

F802 Event ID: 82SE11 10/24/2019 Facility ID: CA070000090 If continuation sheet 51 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.60(a)(3) Support staff. The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. §483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii). This REQUIREMENT is not met as evidenced by: Based on observation, interviews, and record reviews the facility failed to ensure that dietary services had competent and appropriate skills set to ensure proper practice of kitchen sanitation. This deficient practice had the potential for food borne illness affecting 43 out of 43 residents who received food from the kitchen. Findings: During an interview with dish washer F (DW F) on 10/22/19 at 10:00 a.m., DW F stated the dishwashing machine was not reaching a final temperature rinse of 120 F (Fahrenheit, a unit of measurement). DW F further stated, the final rinse temperature should have been at 120 F and the chlorine concentration needed to be a 50 PPM (Parts Per Million, a unit of measurement). DW F also confirmed he used FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 52 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the dish washing machine to wash all dishes, cups and utensils after the breakfast that day even the machine did not rise to 120 F. During an interview with DW G on 10/22/19 at 4:41 a.m., DW G was not able to articulate the process related to accurately performing the tasks to ensure the dishwashing machine was working properly according to the manufacturer's guideline. DW G was observed to test the sanitation solution with an expired test strip. During an interview with dietary cook A (DC A) on 10/23/19 at 7:50 a.m., DC A confirmed the test strip for the quaternary ammonium solution used for the sanitation was expired and needed to be replaced. During an interview with the registered dietician (RD) on 10/23/19 at 10:26 a.m., the RD stated the kitchen staff should have used the manual dishwashing procedure when the dishwashing machine was not within the requirements of the manufacturer based on what's written on the facility policy. A review of the facility's policy dated 8/1/07, "Dishwashing Machine", indicated low temperature machine once the rack is placed in the machine for washing, and dishwashing begins, the temperature should reach 120 F or above. The sanitizer (chlorine) level is checked and should be between 50-100 PPM. A review of the facility's policy dated 8/1/07, "Procedure for Dishwashing - Manual", indicated manual dishwashing procedure should be followed if rinse temperature was not attained in the automatic dish machine operation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 53 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F803 Menus Meet Resident Nds/Prep in Adv/Followed CFR(s): 483.60(c)(1)-(7)

F803 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10/24/2019 §483.60(c) Menus and nutritional adequacy. Menus must§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to follow the menu six of seven residents (24, 20, 8, 106, 33 and 6) when: 1. For Residents 24, 20, 8, 106 and 33 received pureed chicken when the menu stated pureed corn beef. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 54 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. For Resident 6, her meal preference on the meal card was not followed. This failure had a potential for residents receiving repetitive food items that could affect the nutritional status of residents. Findings: 1. During an observation and interview with dietary cook A (DC A) on 10/24/19 at 12:13 p.m., DC A stated there was no pureed corn beef that was served to pureed resident but instead the kitchen staff served pureed chicken. DC A further stated it was a mistake. During a follow up interview with DC A, DC A stated Residents 24, 20, 8, 106 and 33 received pureed chicken instead of pureed corn beef today. During a review of clinical records, the diet order dated 10/21/19 indicated the following: a. For Resident 8, small portion regular pureed diet. Dislikes: None b. For Resident 24, small portion regular fortified pureed diet. Dislikes: Fruit c. For Resident 33, small portion regular pureed diet. Dislikes: Fruit d. For Resident 106, regular portion regular pureed diet. Dislikes: Fruit e. For Resident 20, small portion, no added salt, pureed diet. Dislikes: Fruit During a review of clinical records, the daily therapeutic menu dated 10/24/19 indicated under the column "regular puree" pureed corned beef 4 oz (ounces, unit of measurement). 2. Review of Resident 6's meal card dated 10/21/19 indicated her preference was to be served a wedge salad, macaroni and cheese with ham, potato cheese and succotash, no salt added crisp and no salt added shake. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 55 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an observation and concurrent interview with licensed vocational nurse M (LVN M) on 10/21/19 at 12:04 p.m., Resident 6 was served wedge salad, ground turkey, mashed potatoes, beans and carrots, no salt added crips and no salt added shake. LVN M stated Resident 6's did not receive the meal as it was chosen in the meal card. During an interview with the food services manager (FSM) on 10/23/19 at 2:44 p.m., she stated Resident 6 should have received the food item that was checked on the lunch meal card (wedge salad, macaroni and cheese with ham, potato cheese and succotash, no salt added crisp and no salt added shake).

F804 SS=E Nutritive Value/Appear, Palatable/Prefer Temp F804 CFR(s): 483.60(d)(1)(2) 11/08/2019 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; §483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to prepare food that was appealing and palatable when pureed food served to residents was bland and did not follow the menu for the day. This failure had the potential for the residents who were on a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 56 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pureed diet to consume decreased amount of food due to poor taste. Findings: During a lunch test tray (a tray of food taste for assessing the quality) on 10/24/19, pureed chicken with light brown sauce was served. The pureed chicken meal served was bland in taste compared to the regular chicken meal with a dark brown sauce. This observation was made by two surveyors. During an interview with dietary cook B (DC B) on 10/24/19 at 12:24 p.m., he stated, for the pureed meal he used chicken but he did not add the same sauce as the regular menu. DC B confirmed the pureed chicken meal and the regular chicken meal would not taste the same without the dark brown sauce. Review of the daily therapeutic menu for 10/24/19 indicated regular and pureed meal was coq au vin (chicken with red wine sauce, mushroom and pearl onions).

F812 SS=L Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 11/08/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 57 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: (Part One - Immediate Jeopardy) Based on observation, interview and record review, the facility failed to ensure the dishwashing machine followed the manufacturer's requirements to maintain the proper temperature and the facility failed to ensure the dietary staff and the personnel knew what to do when the dishwashing machine temperature would not meet the manufacturer's requirements. These failures placed all 43 out of 43 residents at risk for food borne illnesses when dishes, cups, and utensils were not sanitized properly. On 10/22/19 at 11:51 a.m., the survey team called an Immediate Jeopardy (IJ; immediate danger or harm to residents or likelihood to harm residents if not corrected immediately) with the administrator (ADM) present regarding the dishwashing machine, when the dishwashing machine did not maintain the proper temperature per manufacturer's requirement and the dietary staff and the personnel were unable to know the necessary steps to do in the event the dishwashing temperature did not meet the manufacturer's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 58 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE requirements. On 10/23/19 at 11:28 a.m., the survey team abated the Immediate Jeopardy with the Admin related to the dishwashing machine temperature, after the team received evidence of a removal plan / immediate action plan. Findings: During a concurrent observation and interview with dish washer F (DW F) on 10/22/19 at 10:00 a.m., DW F stated the dishwashing machine was not working. DW F tested the dishwashing machine and he confirmed the final rinse temperature remained to be at 100 F (Fahrenheit, a unit of measurement) and did not reach 120 F. DW F tested the water using a strip (made of litmus and designed to measure available chlorine in sanitizing solution) to measure the chlorine concentration during the final rinse and DW F stated "ok", while comparing the strip with the bottle represents how much chemical solution was present during the final rinse and stated "50". DW F also added he used the same dish washer machine to clean cup, utensils and dishes this morning after breakfast. During a concurrent observation and interview with DW F on 10/22/19 at 10:01 a.m., DW F confirmed attached to the dishwashing machine was a manufacturer's plate (is a term used to describe the plates fixed to machinery by manufacturer that includes machine's specification requirements) indicated the machine was low temperature and the final rinse temperature needs to be at a minimum of 120 F. During an interview with the Ecolab (an American global provider of water, hygiene and energy technologies and services to the food, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 59 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE energy, healthcare, industrial and hospitality markets) technician (ET) with the presence of the director of dining services (DDS) on 10/22/19 at 10:33 a.m., the ET stated the dishwashing machine final rinse temperature does not need to reach 120 F as long as the chlorine chemical sanitizer was at 50 PPM (parts per million, a unit of measurement). The ET confirmed the dishwashing machine was a low temperature machine and used chemical chlorine to sanitize. During an interview with the DDS on 10/22/19 at 10:05 a.m., the DDS confirmed what the ET stated. The DDS reiterated the dishwashing machine did not need to reach a temperature of 120 F during the final rinse if the sanitizing chemical reached at 50 PPM. During a concurrent observation and interview with kitchen aide H (KA H) on 10/22/19 at 10:15 a.m., KA H was observed starting the tray line (a system of food preparation, in which trays move along an assembly line) and using the dishes, cups, and utensils. KA H confirmed that the dishes, cups, and utensils that were used were cleaned using the dishwashing machine this morning. During an interview with the ET on 10/22/19 at 10:23 a.m., the ET stated the earlier statement related to the final rinse temperature was not accurate and the ET confirmed he "misinformed" the surveyor. The ET stated the dishwashing machine should have reached a minimum temperature of 120 F during the final rinse and with a concentration of 50 PPM of chlorine sanitizer per manufacture requirements. The ET stated that the facility should not have used the dishwashing machine and should have started to use the three compartment sink. The ET also confirmed the requirements were listed on the manufacturer' FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 60 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE plate that was fixed to the machine. During an observation in the kitchen on 10/22/19 at 10:26 a.m., KA H and KA I were still doing the tray line. KA I confirmed "cart one" was completed. During an observation in the kitchen on 10/22/10 at 10:37 a.m., KA H and KA I were still doing the tray line. KA I confirmed "cart two" was completed. During an observation in the kitchen on 10/22/19 at 10:47 a.m., KA H and KA I were still doing the tray line. KA I confirmed "cart three" was completed. A review of the facility's policy dated 8/1/07, "Dishwashing Machine", indicated low temperature machine once the rack is placed in machine for washing, and dishwashing begins, the temperature should reach 120 F or above. The sanitizer (chlorine) level is checked and should be between 50-100 PPM. A review of the facility's policy dated 8/1/07, "Procedure for Dishwashing - Manual", indicated manual dishwashing procedure should be followed if rinse temperature was not attained in the automatic dish machine operation. On 10/22/19 at 11:51 a.m., the survey team called an IJ and informed the ADM to provide the survey team with an immediate measure that would be taken to ensure the safety of the residents. On 10/23/19 at 3:45 p.m., the survey reviewed the evidence of removal plan / immediate action submitted by the facility. The removal plan and immediately action were as follow: 1. The facility and Ecolab District Manager FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 61 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE provided an in-service regarding specific requirements of dishwashing machine per manufacturer's guideline. 2. The facility provided an in-service to use the three compartment sinks (manual dishwashing) when the dishwashing machine was not sanitizing properly. 3. Disposable products should be used until the rinse water temperature stabilized. 4. Maintenance and Ecolab will correct issues. 5. The facility will hourly check the dishwashing machine temperature during the final rinse for 72 hours. 6. The facility will monitor all resident's for possible GI (Gastrointestinal) outbreak for 72 hours. During a concurrent observation and interview with DW G on 10/22/19 at 4:41 p.m., DW G was not able to articulate about the in-service related to the dishwashing machine and its requirements. DW G also used an expired test strip to test the three-compartment sink used for manual dishwashing. On 10/23/19 at 11:28 a.m., the survey team abated the Immediate Jeopardy with the ADM related to the dishwashing, after the team received evidence of an acceptable removal plan/immediate action. (Part Two - Immediate Jeopardy) During an observation, interview and record review the facility failed to maintain food safety based on facility policy and sanitation requirements were not met in the kitchen when: 1. Undated food items were stored in the refrigerator, walk in freezer, walk in refrigerator, kitchen prep area and dry storage area. 2. No evidence of documentation related to cool down procedures. 3. Exhaust vent had black and sticky particles 4. Ice machine was found with some grey FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 62 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE particles. 5. Juice dispenser nozzles (a cylindrical or round spout) had yellowish colored residue 6. Expired milk 7. Food stored inside the resident refrigerator passed allowable date. 8. Storage of cold food at greater than 40 degrees F (Fahrenheit, a unit of measurement) 9. No documentation of cold food log during tray line. These failures had the potential to result in cross contamination and cause food borne illnesses for 43 out of 43 medically vulnerable Residents who consumed food from kitchen. Findings: 1. During concurrent observation and interview with dietary cook A (DC A) on 10/21/19 at 8:19 a.m., three white plastic containers with wheels containing different food items we're not dated. DC A confirmed that inside plastic the containers where sugar, oats and brown rice. DC A also added it should have been dated with a delivery date, used by date and open date. During an observation with DC A present on 10/21/19 at 8:24 a.m., the following was observed inside the walk-in refrigerator: a. An open container of brown sugar with no open date. b. A box containing 26 bananas were undated. c. Four bags of hot dog bun no expiration date. d. Four bags of loaf bread no expiration date. e. Two clear containers of lettuce no received date. f. A container of celery no received date. g. A container of cucumber no received date. h. A container of grape tomatoes no received date. i. A container of tomatoes no received date. j. A container of sweet potatoes no received FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 63 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE date. k. A box of green apples no received date. l. A box of red apples no received date. m. A box of oranges no received date. n. An open container of peeled garlic no opened date. During a oncurrent interview with DC A on 10/21/19 at 8:24 a.m., DC A confirmed all above findings. During an observation with DC A on 10/21/19 at 8:36 a.m., the following was observed inside the walk-in freezer. a. Seven coconut cream pie no received date. b. Open bag of breaded pork no opened date. c. Open bag of chicken teriyaki no opened date. During an interview with DC A on 10/21/19 at 8:43 a.m., DC A confirmed the above observation and added that most boxes inside the walk-in freezer did not have a received date label. During an observation and concurrent interview with DC A on 10/21/19 at 8:41 a.m., DC A confirmed a brown sack labeled "Panko" was opened and with no date when it was opened. During an interview with the registered dietician (RD) on 10/23/19 at 10:26 a.m., the RD confirmed that it was essential to date food items in the kitchen with open date, used by date and expiration date for food safety. A review of the facility's document, "Food Storage & Safety Guide", indicated: a. Follow first in, first out inventory management rule. b. Clearly label all containers including the delivery date and best by date. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 64 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. During an observation and concurrent interview with dietary cook C (DC C) on 10/21/19 at 8:21 a.m., DC C was cutting three whole chicken and arranging them in separate pans. DC C stated that he would cook all chicken a day before. During an interview with DC C on 10/21/19 at 8:43 a.m., DC C confirmed he did not document the cool down procedure when he cooled down the three whole chicken using the three-step method. During an interview with DC A on 10/21/19 at 8:46 a.m., DC A confirmed DC C should have documented the cool down procedure took place related to three whole chicken that were cooked the previous day. A review of the facility's policy dated 8/1/07, "Quick Chill Service & Storage", indicated "record each temperature right after taking the reading on the daily temperature log." 3. During an observation in the kitchen on 10/21/19 at 8:17 a.m., the exhaust vent on top of the stove had black particles. During an observation and concurrent interviews with the DDS and DC A on 10/21/19 at 11:03 a.m., black and sticky particles came off the exhaust vents when the surveyor tried to remove it with plastic spoons. DC C agreed it should have been cleaned. During an interview with the RD on 10/23/19 at 10:26 a.m., the RD stated exhaust vents should be clean. According to the 2017 Federal FDA Food Code, nonfood-contact surfaces of equipment were to be free of accumulation of dust, dirt, food residue and other debris. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 65 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 4. During an observation and concurrent interview with the DDS on 10/21/19 at 10:02 a.m., using a gloved hand, the surveyor wiped the bin of the ice machine using a clean white paper towel provided by the DDS. The DDS confirmed grey particles on the paper towel after wiping the ice bin. During an interview with the RD on 10/23/19 at 10:26 a.m., the RD stated the ice bin should be clean to prevent cross contamination. A review of the facility's policy dated 8/1/07, "Ice Machine Bin", indicated "the ice machine will be emptied, washed and sanitized on a monthly basis." According to the 2017 Federal FDA Food Code, nonfood-contact surfaces of equipment were to be free of accumulation of dust, dirt, food residue and other debris. 5. During an observation and concurrent interview with the DDS on 10/21/19 at 10:17 a.m., four nozzles of the juice dispenser were found with a yellowish colored residue. The DDS confirmed the residue. During an interview with the RD on 10/23/19 at 10:26 a.m., the RD stated the juice dispenser nozzles should have been washed and cleaned thoroughly. A review of the facility's policy dated 8/1/07, "Ice Machine Components", indicated in equipment such as ice bins, beverage dispensing nozzles and enclosed components such as ice makers, cooking oil storage tanks, and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: a. the equipment will be cleaned at a frequency FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 66 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE specified by the manufacturer. b. absent manufacturer's specification, the equipment will be cleaned at a frequency necessary to preclude accumulation of soil or mold. According to the 2017 Federal FDA Food Code, nonfood-contact surfaces of equipment were to be free of accumulation of dust, dirt, food residue and other debris. 6. During an observation and concurrent interview with DC A on 10/21/19 at 8:31 a.m., five half galloon fat free milk bottles had a used by date of 10/19/19. DC A confirmed it was expired and should have been thrown out. During an interview with the RD on 10/23/19 at 10:26 a.m., the RD stated expired food items should have been removed immediately from the kitchen. A review of the facility's policy revised 1/12/17, "Food Product Shelf Life Guidelines", indicated food manufacturer, supplier code dates, use by dates, use thru dates, or expires on dates should always be considered the first level of control. 7. During a concurrent observation and interview with licensed vocational nurse E (LVN E) on 10/21/19 at 1:51 p.m., LVN E confirmed a food container labeled with a resident's name was dated 10/16/19. LVN E stated it was only allowed to keep food that was brought from home 24 hours after it was been brought in. During an interview with the director of nursing (DON) on 10/23/19 at 8:00 a.m., the DON confirmed that food that was brought from home should only be stored for 24 hours. 8. During a concurrent observation and interview with DC A on 10/23/19 at 11:08 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 67 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the Burlogde (is a meal tray transport trolley that keeps the cold food cold and hot food hot) external thermometer read at 59 F for cold food. DC A confirmed when storing food trays to be delivered during lunch time, the temperature should have been below 41 F. During a concurrent observation and interview with DC A on 10/23/19 at 11:09 a.m., DC A confirmed the Burlodge contained food trays for residents in the health center. DC A took the temperature of a carton of milk and it read at 59 F. DC A stated milk should have been stored at below 41 F. During an interview with the DDS on 10/23/19 at 2:31 p.m., the DDS stated when storing cold beverages inside the Burlodge the temperature should have been at less than 41 F. A review of the facility's document, "Food Storage & Safety Guide", indicated eliminate bacterial hazards by maintaining stable and safe internal temperatures at or below 38 to 40 F 9. During a concurrent record review and interview with DC A on 10/24/19 at 12:48 p.m., DC A confirmed an incomplete documentation of the cold food log during tray line. DC A confirmed hot and cold food should be checked and documented before tray line starts.

F865 SS=D QAPI Prgm/Plan, Disclosure/Good Faith Attmpt F865 CFR(s): 483.75(a)(2)(h)(i) 11/12/2019 §483.75(a) Quality assurance and performance improvement (QAPI) program. §483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation; §483.75(h) Disclosure of information. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 68 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section. §483.75(i) Sanctions. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed provide a Quality Assurance and Performance Improvement (QAPI, group of staff working in the facility that helps identify issues and improve the lives of the residents in nursing homes) plan to address falls in the facility and failed to implement an effective oversight on the minimum data set (MDS, mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) transmissions. These failures may result in lack of system in place to ensure residents have adequate plans for their care. Findings: During an interview and concurrent record review of the facility's QAPI plans with the administrator (ADM) on 10/25/19 at 1:11 p.m., the ADM provided quality improvement logs for current QAPI plans on bowel and bladder program, happy/healthy feet program, and 1:1 visits (recreation) program. Issues identified during the survey process were discussed including fall management and MDS oversight. The ADM was unable to present evidence regarding fall management quality improvement measures and stated the director of nursing (DON) would oversee the fall project. The ADM stated the MDS transmissions were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 69 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE done by the minimum data set nurse (MDSN) and was overseen by the DON. The ADM confirmed the DON would provide the survey team with documentation on tracking and performance measures for fall management. The ADM further confirmed the MDSN would show the survey team on the oversight done regarding MDS transmission During an interview with the MDSN on 10/25/19 at 1:53 p.m., she stated there was no tracking done to ensure all transmission were completed and nobody would oversee her (cross reference F640). The DON was unavailable for interview and was not able to provide any documentation for fall management quality improvement measures.

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 11/12/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 70 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 71 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure staff implemented proper infection control practices when: 1. A nurse performed a dressing change in the clean utility room; and 2. Staff did not wash residents' hands prior to a meal. These failures had the potential to spread infection in the facility. Findings: 1. During an observation on 10/21/19 at 11:20 a.m., licensed vocational nurse D (LVN D) changed Resident 24's dressings in a utility room. LVN D used the scissors to cut the dressing on the left arm. After removing the dressing, she washed her hands in the sink and washed the scissors in the sink with soap and water. LVN D used the scissors to cut the dressing on the left leg. After removing the dressing, she washed her hands in the sink and washed the scissors in the sink with soap and water. During a concurrent interview, LVN D stated she usually changes resident's dressings in their room but was told by another nurse to use the utility room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 72 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an observation on 10/21/19 at 11:32 a.m., LVN D used the scissors to cut the dressing on the right leg. After removing the dressing, she washed her hands in the sink and washed the scissors in the sink with soap and water. During an interview on 10/24/19 at 10:09 a.m., the director of staff development (DSD) stated the utility room was considered a clean room. The DSD stated it was not okay for Resident 24 to have her dressings changed in the utility room because the room becomes contaminated. The DSD also stated treatments/dressing changes should be done in the resident's room. The DSD stated the facility's only eye wash station is by the sink in the utility room . The DSD stated the eye wash station should be kept clean and scissors should not be washed in the sink. The DSD stated scissors should be disinfected by using a chemical. The facility did not provide a policy regarding dressing changes and use of the utility room.

F883 SS=D Influenza and Pneumococcal Immunizations CFR(s): 483.80(d)(1)(2)

F883 11/12/2019 §483.80(d) Influenza and pneumococcal immunizations §483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 73 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident's representative has the opportunity to refuse immunization; and (iv)The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. §483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident's representative has the opportunity to refuse immunization; and (iv)The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 74 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on record review and interview, the facility staff failed to ensure one of five randomly selected residents (Resident 18) received a pneumococcal vaccine based on the facility's policy. This failure had the potential to endanger the health and safety of Resident 18. Findings: During a review of the clinical record for Resident 18, the Immunization/Serology Report dated 10/24/19 indicated Resident 18 was admitted on 10/31/18 and received a dose of pneumococcal vaccine in the year of 2005. During an interview with the director of staff development (DSD) on 10/25/19 at 1:03 p.m., the DSD stated there was no evidence that another pneumococcal vaccine was offered to Resident 18. The DSD confirmed that Resident 18 received his last pneumococcal vaccine in the year of 2005. The DSD stated a pneumococcal vaccine should be offered to residents every five years. A review of the facility's policy dated 3/2019, "Influenza and Pneumococcal Immunization", indicated the community will offer influenza and pneumococcal immunizations to resident based on current CDC (Centers for Disease Control and Prevention) recommendations. It further indicated, for those who previously received PPSV23 (Pneumococcal polysaccharide vaccine, protects against 23 types of pneumococcal bacteria) when aged < (less than) 65 years and for whom an additional dose of PPSV23 was indicated when aged > (greater than) or equal to 65 years, the subsequent PPSV23 dose should be given > FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 75 of 76 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555342 (X3) DATE SURVEY COMPLETED 10/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VIEW MANOR 22445 Cupertino Rd Cupertino, CA 95014 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or equal to a year after PCV13 (Pneumococcal conjugate vaccine, protects against 13 types of pneumococcal bacteria) and > or equal to five years after the most recent dose of PPSV23.

F908 SS=E Essential Equipment, Safe Operating Condition F908 CFR(s): 483.90(d)(2) 11/11/2019 §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. This REQUIREMENT is not met as evidenced by: During an observation and interview the facility failed to maintain essential equipment when the walk-in freezer had ice build-up. This failure had the potential to create an unsafe and unsanitary environment in the kitchen for 43 out of 43 residents who received food from the kitchen. Findings: During an observation and concurrent interview with dietary cook A (DC A) on 10/21/19 at 8:40 a.m., DC A confirmed the presence of an ice build-up on top of a white box on a rack under a fan in the walk-in freezer. During an interview with the registered dietician (RD) on 10/23/19 at 10:26 a.m., the RD stated it's unusual to have ice build-up in the walk-in freezer. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 82SE11 Facility ID: CA070000090 If continuation sheet 76 of 76