Other·December 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 an abbreviated survey regarding investigation of entity reported incident and complaints conducted on 11/25/19. For Entity Reported Incident CA00663688 regarding Quality of Care/Treatment; Resident Safety, a federal deficiency was identified (see

F689). In addition, a Class "B" citation was issued. For Complaints CA00663766 and CA00663199 regarding Quality of Care/Treatment; Resident Safety, the department did not substantiate a violation of federal or state regulations. Inspection was limited to the specific entity reported incident and complaints investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 38174, Health Facilities Evaluator Nurse.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that - 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: EN3411 Facility ID: CA220001041 If continuation sheet 1 of 4 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: _______________ 555792 (X3) DATE SURVEY COMPLETED 11/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVALE POST-ACUTE CENTER 1291 S Bernardo Ave Sunnyvale, CA 94087 (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 §483.25(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: Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided for one of two sampled residents (1) when Resident 1 was found in another resident's (2) room uninvited. This failure resulted in an incident of inappropriate sexual behavior of Resident 1 and had the potential to cause psychological harm to Resident 2. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility with a diagnoses of dementia (decline in memory and other mental abilities) and schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves). Review of Resident 2's clinical record indicated she was admitted to the facility with a diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and schizophrenia. Review of Resident 1's Physician Order dated 11/14/19 indicated monitor and document whereabouts as resident should not go into other resident's room unless invited. The frequency of the order was written every hour from 6:00 a.m. to 10:00 p.m. Review of Resident 1's care plan dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EN3411 Facility ID: CA220001041 If continuation sheet 2 of 4 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: _______________ 555792 (X3) DATE SURVEY COMPLETED 11/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVALE POST-ACUTE CENTER 1291 S Bernardo Ave Sunnyvale, CA 94087 (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 11/14/19, indicated he had socially inappropriate and disruptive behavior as evidenced by wondering into other patients' room. Resident 1 exhibited inappropriate sexual behavior. The approach was to frequently monitor his whereabouts. Review of Resident 1's Progress Notes dated 11/15/19 indicated at around 5:00 a.m., Resident 1 was found inside Resident 2's room. Resident 1 was attempting to kiss Resident 2. During an observation and concurrent interview with Resident 2 on 11/18/19 at 1:45 p.m. Resident 2 stated on 11/15/19 around 5:00 a.m., she was awakened by Resident 2's touching her legs and attempting to kiss her on her mouth. Resident 2 stated, certified nursing assistant A (CNA A) came after she screamed for help. During an interview and concurrent record review with the assistant director of nursing (ADON) on 11/18/19 at 2:40 p.m., the ADON confirmed the order for monitoring was entered from 6:00 a.m. to 10:00 p.m. and there was no evidence Resident 1 was not monitored after 10:00 p.m. The ADON stated Resident 1 did not need monitoring after 10:00 p.m., because Resident 1 would be sleeping. During a telephone interview with CNA A on 11/19/19 at 1:50 p.m., he confirmed on 11/15/19 at around 5:00 a.m., he heard a scream coming from Resident 2's room, and found Resident 1 inside Resident 2's room. Resident 1 was standing from his wheelchair and attempting to kiss Resident 2. During a telephone interview with CNA B on 11/20/19 at 12:05 p.m., CNA B confirmed he was assigned for Resident 1 on 11/15/19. At FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EN3411 Facility ID: CA220001041 If continuation sheet 3 of 4 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: _______________ 555792 (X3) DATE SURVEY COMPLETED 11/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNYVALE POST-ACUTE CENTER 1291 S Bernardo Ave Sunnyvale, CA 94087 (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 around 5:00 a.m., CNA B stated he went inside Resident 1's room to change Resident 1's roommate's brief. CNA B stated he did not see Resident 1 in his bed and he did not check Resident 1's whereabouts. CNA B stated he was not aware Resident 1 needed to be monitored. During an interview with the administrator (ADM) on 11/20/19 at 1:10 p.m., the ADM confirmed on 11/15/19, Resident 1 was inside Resident 2' room from 5:15 a.m. to 5:19 a.m. The ADM stated the incident was avoidable if the facility continued to have monitored Resident 1's whereabouts. Review of the facility's policy dated 7/2017, "Safety and Supervision of Residents", indicated resident safety, supervision and assistance to prevent accidents were facilitywide priorities. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EN3411 Facility ID: CA220001041 If continuation sheet 4 of 4