Health inspection·October 14, 2022

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure safety when Resident 24 administered his own medication and it was not stored properly for one of twelve sampled residents (Resident 24). This failure had the potential to results in improper use of the medications. Residents Affected - Few Findings: During the facility initial tour observation on 10/10/22 at 9:48 a.m., one tube of Neosporin ointment (used to prevent and treat minor skin infections caused by small cuts, scrapes, or burns) medication was observed on Resident 24's bedside table unattended. During a concurrent observation and interview on 10/10/22 at 9:54 a.m., with the director of staff development (DSD), She acknowledge the above observation and she stated that it was not the facility's practice to leave medication at bedside table. DSD also stated there was no physician order for Resident 24 to apply the medication. She further stated the medication should have been kept inside the treatment cart. During an interview on 10/11/22 at 8:30 a.m., with Resident 24 he stated the Neosporin ointment was brought by his family member two weeks ago to apply to his skin tear. He further stated that he used the neosporin ointment two times. During a concurrent interview with the DSD and record review on 10/10/22 at 2:30 p.m., she reviewed Resident 24's clinical records and she stated there was no physician order for the Neosporin ointment. The facility policy and procedure titled Storage of Medication dated 01/2021, indicated medications and biologicals are stored properly. The medication supply should have been accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications are allowed access to medication carts. Medication rooms, cabinets and medication supplies should have been locked when not in use or attended by persons with authorized access. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 2 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0574 The resident has the right to receive notices in a format and a language he or she understands. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure contact information of the California Department of Public Health District Office (CDPH DO) was accessible for four of four residents (Residents 4, 15, 16, and 20). This failure had the potential for residents not to file for complaints and grievances. Residents Affected - Few Findings: During an interview with Residents 4,15,16, and 20 on 10/11/22 at 10:41 a.m., in the dining room for resident council meeting. All of them stated they did not know how to contact CDPH DO. They have not seen posters or signages indicating CDPH DO contact information. During an interview with Resident 16 on 10/22/22 at 10:45 a.m., she stated there was no information provided to them on the filing of complaints with CDPH DO since February 2022. She further stated no posters were available for them inside the facility on how they could call, e- mail, and contact CDPH DO. During a concurrent observation and interview on 10/11/22 at 11:03 a.m. with Life Enrichment Specialist (LES, activity director), there was no accessible postings or signages displayed for the residents. LES stated CDPH DO contact information should be accessible to residents. A review of the facility's resident council meeting minutes did not indicate any information on how to file a grievance or complaint with CDPH DO. During an interview with director of nursing (DON) on 10/14/22 at 8:54 a.m., she stated the CDPH DO contact information posters were taken off during the facility repair and was not placed back. She further acknowledged the CDPH DO contact information should be made available and accessible for residents right if they need to file complaints and grievances at all times. Review of the facility's policy titled Resident Rights and Community Responsibilities dated 11/2016, it was indicated the facility must ensure the residents remains informed of the agency responsible for their protection and advocay. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 3 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary care and services in accordance with professional standards of practice for three of 12 residents (12, 14 and 16) when: Residents Affected - Few 1. Resident 12 had an arteriovenous (AV) shunt (a connection made between an artery and a vein) for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) on her left upper arm. Certified nursing assistant D (CNA D) stated he took Resident 12's blood pressure on her left wrist; 2. Restorative nursing assistant (RNA) program was not followed for Resident 12 to provide two times per week instead of three times per week. Resident 16's RNA program three times per week instead of five times per week as ordered by the physician; and 3. Resident 14 had a Foley catheter (FC, tube that is inserted into the bladder to drain urine) drainage was not monitored and recorded. These failures had the potential to result in residents not receiving proper treatment and their needs not being met. Findings: 1. Review of Resident 12's admission Record indicated she was admitted to the facility on [DATE] with dependence on renal dialysis diagnosis. Review of Resident 12's physician order indicated she had an AV shunt on her left upper arm. During an interview with CNA D on 10/14/22 at 3:37 p.m., CNA D stated he took Resident 12's blood pressure on her left wrist. CNA D requested to observe Resident 12 in her room to confirm his statement. After observing Resident 12 in her room. CNA D confirmed he took Resident 12's blood pressure on her left wrist. Review of the facility's policy, Dialysis, AV Shunt Care, dated 2/2009, indicated Protect the extremity where the shunt is located, . Pressure above or below the extremity should be avoided at all times . Blood pressure or venous puncture will not be performed on the extremity where shunt is located. 2a. Review of Resident 12's admission Record indicated she was admitted to the facility on [DATE] with muscle weakness diagnosis. Review of Resident 12's physician order, dated 9/23/22, indicated the RNA program orders for active range of motion (AROM) on both upper extremities and both lower extremities 10 repetitions times three sets, three times per week for 90 days, and for sit-to-stand exercises using rail in hallway 3-5 times or as tolerated, three times per week for 90 days. Review of Resident 12's Restorative Nursing Record for 9/2022 and 10/2022 indicated for the week of 9/26/22, Resident 12 received RNA two times on 9/26/22 instead of three times per week as ordered by the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 4 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm During an interview with the director of nursing (DON) on 10/14/22 at 4:34 p.m., she confirmed for the week of 9/26/22 Resident 12 received RNA two times a week instead of three times per week as ordered by the physician. 2b. Review of Resident 16's admission Record indicated she was admitted to the facility on [DATE]. Residents Affected - Few During an interview with Resident 16 on 10/10/22 at 9:13 a.m., Resident 16 stated she supposed to ambulate every day but the RNA did not provide ambulation. Review of Resident 16's physician order, dated 10/6/22, indicated she had RNA order for ambulate using front-wheeled walker (FWW) for 40-75 feet with contact guard assist (CGA)/minimal assistance plus wheelchair to follow up and using left knee brace five times per week for 90 days. Review of Resident 16's Restorative Nursing Record indicated from 10/8/22 to 10/14/22, Resident 16 received RNA three times on 10/11/22, 10/12/22, and 10/13/22 instead of five times per week as ordered. During an interview with the DON on 10/14/22 at 4:36 p.m., she confirmed from 10/8/22 to 10/14/22, Resident 16 received RNA three times on 10/11/22, 10/12/22, and 10/13/22 instead of five times per week as ordered. Review of the facility's RNA Job Description, dated 12/2018, indicated to assist the physical, occupational, and speech therapists to carry out physician ordered for plan of care. 3. Review of Resident 14's clinical record indicated he was admitted with diagnosis including senile degeneration of the brain (loss of intellectual ability) malignant neoplasm (abnormal growth of tissue in the body), and retention of urine. Review of Resident 14's Minimum Data Set (MDS, a standardized assessment tool) dated 9/22/22, indicated his cognition was not intact. During a concurrent observation and interview with Licensed Vocational Nurse B (LVN B) on 10/10/22 at 9:20 a.m. inside Resident 14's room, FC was bright yellow in color, and cloudy with white particles floating inside the bag. LVN B stated FC drainage should have been monitored, recorded, and should have been reported to a physician. Review of Resident 14's nursing care plan, dated 9/12/22, indicated to monitor for signs and symptoms of urinary tract infection for cloudy, concentrated urine and notify medical doctor (MD) if present. There was no documented evidence Resident 14's FC urinary drainage was monitored and recorded. During a follow up observation and interview with infection preventionist (IP) on 10/12/22 at 11:18 a.m. inside Resident 14's room, she stated the FC urinary drainage was concentrated, and cloudy with sediments. IP further stated the urinary drainage should have been monitored and reported to the physician. During an interview with director of nursing (DON) on 10/14/22 at 8:28 a.m. she stated cloudy and concentrated with sediments urinary drainage are abnormal findings and should have been documented by the licensed nurse and reported to a prescriber. She further stated nursing care plans should be implemented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 5 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy titled Urinary Catheters - General Guidelines: dated 10/19, indicated urinary output would have been monitored during daily care for change in status which include but are not limited to: color, consistency, and sediment. The physician will be notified of significant changes as appropriate. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 6 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a 12 percent (% unit of measurement) error rate when three medication errors out of 25 opportunities were observed during a medication pass for three of 11 residents (9, 17, and 231). These failures resulted in medications not given in accordance with prescriber's orders, which had the potential for residents to not receiving the full therapeutic effect of the medications or had the potential for preventable side effects for the residents. Residents Affected - Few Findings: 1. During a medication pass observation on 10/11/22 at 4:18 p.m., licensed vocational nurse E (LVN E) administered Artificial Tears to Resident 17 one drop to her right eye and two drops to her left eye. Review of Resident 17's physician order, dated 8/28/19, indicated she had an order for Refresh Tears ophthalmic solution 0.5%, instill one drop to both eyes two times a day for dry eyes. During an interview with LVN E on 10/11/22 at 5:59 p.m., she confirmed she administered Artificial Tears to Resident 17 one drop to her right eye and two drops to her left eye instead of one drop to both eyes as ordered by the physician. 2. During a medication pass observation on 10/13/22 at 11:21 a.m., licensed vocational nurse A (LVN A) check the Resident 231 blood sugar, and Resident 231 blood sugar reading was 211. Review of Resident 231's physician order, dated 10/1/22, indicated Resident 231 had an order for lispro (insulin that used to control high blood sugar) 100 units/milliliter (ml, a metric unit of volume), inject 3 units if his blood sugar was 211, but LVN A drew 3.5 units of lispro into the insulin syringe and about to inject it to Resident 231's left abdomen. Reviewed the insulin unit reading on the syringe with LVN A, and she acknowledged there was 3.5 units of lispro in the syringe. LVN A ejected some lispro insulin out of the syringe to have 3 units left and she injected the insulin to Resident 231's left abdomen. 3. During a medication pass observation on 10/13/22 at 1:14 p.m., LVN A administered Artificial Tears one drop to each eye for Resident 9. Review of Resident 9's physician order, dated 8/20/22, indicated she had an order for Artificial Tears two drops to each eye three times a day for dry eyes. During an interview with LVN A on 10/13/22 at 2:28 p.m., LVN A reviewed Resident 9's physician order and confirmed she administered Artificial Tears to Resident 9 one drop to each eye instead of two drops to each eye as ordered by the physician. Review of the facility's policy, Medication Administration - General Guidelines, dated 1/2021, indicated medication administration should have been in accordance with written orders of the prescriber. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 7 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based of observation, interview, and facility document review, the facility failed to ensure the registered dietitian effectively carried out the functions of the Food and Nutrition Services as evidenced by lapses in the delivery of services associated with staff competency (Cross-reference F802), portion sizes for puree diets (cross-reference F803), food safety and sanitation (Cross-reference F812), and pests in the kitchen (Cross-reference F925). This failure to ensure food and nutrition services systems are accurately and effectively delivered may result in food borne illness for a highly susceptible population and/or not meeting the nutritional needs of the 31 residents who ate food by mouth from the kitchen out of a facility census of 32. Findings: Review of the facility job description titled Registered Dietitian (RD), revised October 2019 and signed 3/23/20 by Registered Dietitian (RD) and Administrator (ADMIN), indicated under Job summary: under the direction of the Director of Dining Services, the Registered Dietitian .works as a team with the [NAME] President of Nutrition and Dining Service and Manager of Nutrition and Dining Services to ensure modified diets are followed, appropriate care center in-services are completed, sanitation audits of the kitchen are completed .and under essential functions .establishes portion sizes, instructs the above personnel in foods to be served to residents on therapeutic diets, supervises preparation and service of food to residents, follows highest standards of cleanliness, follows all federal, state and corporate policies, health codes and guidelines in preparation and handling of foodstuffs, carries out supervisory responsibilities in accordance with the company's policies and applicable laws, responsibilities include directly supervising all employees in the Care Center dining department. During an interview on 10/11/22 at 9:35 a.m., RD stated she works at this facility full time, has been here 2 ½ years, and spends most of her time on the Skilled Nursing Facility (SNF). RD further stated that the Director of Dining Services (DDS) and the Executive Chef (EC) look after the kitchen and she (the RD) does mostly clinical nutrition work at the facility. She stated she does do kitchen audits three to four times per week. RD stated that DDS is fulltime for the whole building including assisted living and memory care not just SNF. During an interview on 10/11/22 at 10:01 a.m., DDS stated she was in charge of the entire kitchen for the entire campus, she oversees the kitchen and supervise to the EC and RD. During a concurrent interview at that time, RD confirmed DDS was her supervisor and the main person over the kitchen. RD does kitchen inspections weekly and monthly and gives any findings to DDS on a monthly basis, but if there was something major she would share immediately with DDS. RD stated she did not have direct contact with the Administrator (ADMIN) regarding kitchen issues for the SNF, RD goes through DDS. During the Federal Re-certification survey conducted from 10/10/22 to 10/14/22, multiple issues were identified with: a) Staff competency when the staff member who made puree foods did not prepare puree foods (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 8 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 correctly (Cross-reference F802); Level of Harm - Minimal harm or potential for actual harm b) Serving the wrong portion size of the entrée for pureed diets (Cross-reference F 803); Residents Affected - Many c) Storing and preparing foods and a safe and sanitary environment including time temperature for safety foods (TCS =food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation) were improperly cooled down and/or stored above 41 degrees Fahrenheit (°F), a can opener and meat slicer were found stored dirty, food storage bins and utensils drawers had residue build-up, meat had no use by dates in the refrigerator, thawing meat had no dates to indicate when it was put in the refrigerator, cups and mugs were stored unclean, (Cross-reference F812); and d) Flies and ant found in the kitchen (Cross-reference F925). During a review of daily RD kitchen audits titled Kitchen Daily Audit dated April, May, July, August, September 2022, indicated RD found some similar issues as identified during the survey like foods lacking dates, puree foods lacking flavor, flies and ants in kitchen. During a review of RD monthly kitchen audits, dated 4/29/22, 5/27-28/22, 6/26/22, 7/21-26/22, 8/22-23/22, 9/26/22, indicated RD found some similar issues as identified during the survey like ants and flies in the kitchen and lack of dates on foods. In one out of the six months of audits, proper cooling procedure were observed, such as cooling foods in shallow containers, and not deep sealed containers, facilitating foods to cool quickly as required and Potentially hazardous foods are cooled from 135°F (degrees Fahrenheit a unit of measurement for temperature) to 70°F within 2 hours; from 70°F to 41°F within 4 hours; the total time for cooling from 135°F to 41°F should have not exceed six hours were checked, the other five months were not checked. During an interview on 10/13/22 starting at 1:35 pm, RD stated if the cooling of foods was not checked on the audit form then it means she did not see anything cooling; she does not review the cool down logs to ensure accuracy. During a concurrent record review of RD job description at that time, RD confirmed her job description says she supervises dining service staff, but she did not do her part. She further stated she did not evaluate the employee job performance at this time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 9 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service when one staff did not properly prepare pureed foods (a texture modified diet that minimizes the amount of chewing required and increases the ease of swallowing). This failure had the potential to decrease the attractiveness, flavor, and nutrients, possibly resulting in decreased dietary intake and may result in not meeting the nutrition needs for six residents receiving puree foods out of a facility census of 32. Findings: During a review of the facility menu titled Daily Therapeutic Menu dated 10/11/22 indicated for Lunch Tuesday the puree diet was to get puree chicken cacciatore, pureed risotto, and pureed mixed vegetables. The regular diet was to get chicken cacciatore, risotto, and mixed vegetables. a. During a concurrent observation and interview on 10/11/22, at 10:05 a.m., in kitchen, Food Service Worker H (FSW H) was preparing the risotto puree (a soft Italian rice dish). She mixed vegetable broth with the prepared risotto then blended in a blender. FSW H then poured the fully liquid mixture into a bowl, added two ladles (2 ounce each) of thickener and mixed with a wire whisk until thickened. She stated she used 48 ounces of broth with 16 ounces of risotto into the blender then added thickener and blended until it was mashed potato consistency. FSW H further stated rice has a lot of starch, so it sticks in the blender if don't add a lot of liquid. Review of facility document titled Puree Foods Break Down, undated, indicated for Rice: two pounds rice, five cups water, ½ teaspoon vegetable base, Needed process: Blend, ½ cup thickener. b. During an observation and concurrent interview on 10/11/22 at 10:14 a.m., FSW H was taking temperatures of foods for lunch, the pureed chicken appeared uniformly white, while the chicken cacciatore for the regular diet had vegetables such as tomatoes, olives, onions on top. FSW H confirmed she made the chicken puree, and she pureed plain chicken for all the purees because some of them have a tomato allergy and/or a dislike of tomatoes. Review of facility recipe titled Chicken Cacciatore indicated in addition to chicken such ingredients as onion, garlic, yellow bell pepper, carrot, mushrooms, black olives, thyme, oregano, parsley, basil, red wine, crushed tomatoes, tomato paste, [NAME] tomatoes, red pepper flakes, and had no instructions for puree. Review of the facility meal tickets titled Lunch dated 10/10/22 for Residents # 4, 5, 8, 10, 20, 22 indicated their diet consistency was pureed and that none had allergy or dislike to tomatoes. c. During a concurrent observation and interview on 10/11/22 at 10:14 a.m., FSW H was taking temperatures of the puree vegetables, she stated these are mixed vegetables and are not the same vegetables as the regular diet was having for lunch today. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 10 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 10/11/22 at 12:05 p.m., with FSW H, with the presence of Registered Dietitian (RD), on how she made the puree vegetables today, FSW H stated she put two cups of vegetables with one cup vegetable stock in the blender, then used 2-3 ounces of thickener in a bowl and whisked, to make a mashed potato consistency. Review of facility document titled Puree Vegetables Break Down, undated, indicated to make pureed Vegetables mixed/fresh the following: four pounds vegetables, 2 cups water, 1 teaspoon vegetable base, Needed process: Blend, one cup thickener. Complaints about food not being appetizing were received so a test tray of the regular and puree diets was conducted on 10/11/22 at 11:53 a.m. During the test tray in the dining room with the RD, the puree chicken was white and tasted bland and did not have the same flavors as the regular chicken which had vegetables including tomatoes, olives, onions on top. RD confirmed the observation and agreed the pureed chicken was bland. RD stated she heard how FSW H described how she made the pureed chicken and she should have pureed the same chicken from the regular diet for the puree diets instead of plain chicken. She further stated not all purees have an allergy to tomatoes, and FSW H could have made at least some puree chicken the same as regular chicken. The puree vegetables were gummy and the regular vegetables had good flavor; RD confirmed the puree vegetables were gummy and said the taste was okay for the puree vegetables similar to regular, but they appeared to be different vegetables in color and the texture may be due to having used thickener. During an interview on 10/13/22 at 10:14 a.m., Director of Dining Services (DDS) said the Puree Food Break Down and Pureed Vegetables Break Down recipe sheets are a general guide for making pureed foods, and the facility does not have all the menu items that are served on the recipe sheets. She further stated the facility does not have any other specific guidelines to guide staff in making pureed foods and there are no instructions for puree preparation on each recipe. During an interview on 10/13/22 at 10:02 a.m., FSW H said she has worked at this facility since June 2022; and had previously been a cook for several years at another facility. She stated she was trained at the other facility to make pureed foods. She further stated to make pureed foods she usually uses one cup of the food and adds 1/4 cup liquid (broth), and it depends on the food how much thickener to use. During a concurrent record review of facility recipe Puree Foods Break Down, undated, looking at the recipe for rice, FSW H stated their blender does not fit two pounds of rice so she can not follow the recipe on the Puree Foods Break Down sheet . During an interview on 10/12/22 at 10:37 a.m., with the Executive Chef (EC) in the presence of DDS confirmed that whatever was cooked for the regular menu should have been cooked for the purees, using the same food but puree it. DDS confirmed should have puree same food as regular recipe. During an interview on 10/13/22 at 10:25 a.m., RD confirmed the nutritive value goes down if too much liquid or thickener was used when making pureed foods. During an interview on 10/13/22, at 2:08 p.m., with the RD, how to evaluate employees doing their job correctly, she stated she does not evaluate the employee job performance at this time. RD stated when making puree foods they should have been made with the same foods as the regular diet. RD stated that when making puree vegetables cooks should use the liquid that was already with the vegetables, put that in the blender and then determine whether additional liquid or thickener is needed. When making puree, cooks should only add liquid or thickener as needed. RD confirmed the way FSW H made the puree risotto did not sound correct. RD stated risotto is already creamy, and the cook could have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 11 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some blended without adding any liquid or thickener, if it was a little dry then could add a little vegetable broth, and if needed thickener. RD said staff maybe need a training on puree preparation. During a record review of the facility monthly in-service, titled Pureed Food dated 8/22/22, indicated Food should have been pureed based on the menu/spreadsheet and always after the Final Cooking of the regular food. Some exceptions are there when we have sandwich. Always check the spreadsheet. FSW H's name was on the sign-in sheet. During a review of the facility's document titled Modification in Consistency and Texture- Pureed Diet, undated, indicated This diet was composed of regular foods that are blenderized or have natural pudding like texture. During a review of the facility's policy and procedure (P&P) titled Food Preparation- Dietetic Service- Food Service, dated 1/20/20, indicated Recipes for all items that are prepared for regular and therapeutic diets should have been available, used to prepare attractive, palatable meals in which nutritive values, flavor, and appearance are conserved. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 12 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, staff interview, and facilty record review, the facility failed to ensure the planned menu was followed when two out of two residents (Residents # 20, 22) on regular pureed diets (texture modified diets for people with chewing or swallowing difficulties) were served the wrong portion size for the entrée. This failure had the potential to result in not meeting the nutritional needs thus further compromising the nutritional status of these residents, out of a facility census of 32. Findings: Review of the facility menu titled Daily Therapeutic Menus for Monday 10/10/22 Lunch indicated for the Puree diet, the following items: Puree Stuffed Bell Pepper (6 oz) (ounce), Puree Yellow Squash ½ cup, Mashed Potato (4 oz). During an observation of the lunch meal service on 10/10/22 starting at 10:41 a.m., in the presence of the Registered Dietitian (RD), Foodservice Worker G (FSW G) portioned foods onto plates and used a gray scoop to serve all the puree stuffed bell pepper. During a concurrent interview on 10/10/22 at 11:05 a.m., after all the plates were served, FSW G confirmed the gray scoop was a four-ounce scoop and she used it to serve the puree stuffed bell pepper to all the puree diets today. During an interview and concurrent record review of the menu at that time, RD confirmed FSW G should have served a six-ounce scoop of the puree stuffed bell pepper. RD stated the puree diets received the wrong portion of the entrée. Review of the facility meal tickets titled Lunch dated 10/10/22 for Residents #20 and 22, indicated under diet order, consistency, and meal size: CCHO NAS Pureed Regular and Regular Pureed Regular, respectively. During an interview on 10/13/22 starting at 1:35 p.m., RD stated she expects staff to follow the menu for serving sizes. Review of facility policy and procedure titled Food Portion Control dated 1/1/20, indicated to know the standard portion for each item on the menu for both regular and therapeutic diets and use the appropriate scoop, measuring cup or ladle when serving portions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 13 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident group agreed to a meal span of more than 14 hours between a substantial evening meal and breakfast the following day. This failure had the potential to not meet the needs of 31 residents eating meals at the facility out of a census of 32. Findings: During an observation on 10/12/22 at 11:56 a.m., the mealtimes posted in the dining room were Breakfast 7:35 a.m., Lunch 11:30 a.m., Dinner 4:55 p.m. The waiting time was about 14 hours and 40 minutes between dinner and breakfast. During the resident council meeting on 10/11/22 at 10:06 a.m., four residents stated the waiting time from dinner to breakfast takes too long. During an interview on 10/13/22 at 9:02 a.m., Resident 16 confirmed it was not ok for them to wait from dinner to breakfast more than 14 hours to have something to eat and she does not remember signing an agreement for it to be longer than 14 hours. During an interview on 10/13/22 at 1:35 p.m., Registered Dietitian (RD) confirmed mealtimes are 7:35 a.m. for breakfast, 11:30 p.m. for lunch, and 4:55 p.m. for dinner. During an interview on 10/14/22 at 9:54 a.m., RD stated the facility did not have documented evidence that the mealtime span between dinner and breakfast of more than 14 hours was approved by the residential council. She further stated they have a new president of residential council, who started in [DATE] and the issue will be put on the agenda for this month's upcoming residential council meeting. During a review of the facility's policy and procedure (P&P) titled Dining Services -3 meals per day dated 1/1/20, indicated, it was the policy of this facility that 3 meals shall be served daily with no more than 14-hour span between the last meal and the first meal of the following day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 14 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure safe sanitary practice in the kitchen. The facility failed to ensure food was stored and prepared under sanitary conditions when: Residents Affected - Many 1. Time temperature control for safety foods (TCS - another name for Potentially Hazardous food)) that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation) were not properly cooled down, 2. Cups for fruit, and mugs for juice were stored with residue inside; 3. The meat slicer was stored with food particles on it; 4. The can opener had residue build-up around the blade and base; 5. No use by dates labeled on the eight pieces of vacuumized flat iron steak inside the walk -in refrigerator and thawing meat had no dates to indicate when it was put in the refrigerator; and 6. Four food storage bins and three utensil drawers had residue build-up, These failures had the potential to cause foodborne illness for the 31 residents receiving food from the kitchen out of a census of 32. Findings: 1.a. During a concurrent observation and interview on 10/10/22, at 8:50 a.m., inside the walk-in refrigerator with Registered Dietitian (RD) and Sous Chef (SC), a potato salad (a TCS food) was in a large white plastic container approximate size of 2'x3'x1' (feet) covered with a tightly fitting plastic lid dated 10/08/22. The temperature in the center was 43.5 ºF and 44.1ºF (degrees Fahrenheit). The RD confirmed the observation and said the potato salad had been in the refrigerator since 10/8/22 and was for dinner tonight. She further stated that the potato salad should be 41ºF and should be thrown away. SC stated it was approximately 30 pounds of potato salad in that one container. During a concurrent interview and record review at that time of the kitchen log titled Food Cooling Temperature Log dated August 2022, potato salad temperature was reviewed. The RD and SC confirmed the cool down log had no date written on the log for when the potato salad was made, the log was actually from October 2022, and were unable to determine who made the potato salad. On 10/11/22 at 9:14 a.m. in the presence of RD, thermometers used to measure potato salad temperatures were calibrated (a process using ice water to ensure thermometers are reading temperatures correctly). RD confirmed the correct calibration. Review of facility kitchen log titled Food Cooling Temperature Log, dated August 2022, indicated Potato Salad under Food item quantity 40, with no date when it was made, start temperature was 140ºF at 12:00, temperature at 2:00 (2 hours later) was 130 ºF and at 4:00 (2 hours later) was 40ºF, the Corrective action column was blank. The log indicated the food must reach 70 ºF of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 15 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm below within the first two hours and Food must reach 41 ºF or below within the next 4 hours. Under Action plan and follow-up indicated if the food does not meet minimum temperatures within the required time frame, item must either: 1. Reheated to 165 ºF for 15 seconds and the cooling process re-instituted from the beginning, 2. If there was no adequate time to reinstitute the cooling process, and the food must be discarded. Residents Affected - Many During an interview and concurrent record review of Food Cooling Temperature Log, dated August 2022, on 10/13/22 starting at 1:35 p.m., RD confirmed the potato salad was not properly cooled down, should have been thrown out after 2 hours not reaching 70ºF, should have had a date when it was made and cooled down on the cool down log, and should have been put in a more shallow container and stirred to facilitate faster cooling. During a review of the facility's policy and procedure (P&P) titled Quick Chill Service & Storage, dated January 1, 2020, the P&P indicated, Establish Control Procedures for effective record keeping documenting safe cool down and storage of hot food, Cooked potentially hazardous food may be rapidly cooled from 135 ºF to 70 ºF within a 2-hour period. Food can then continue to be cooled from 70 ºF down to 41 ºF within an additional 4-hour period.; Place food in shallow pans. b. During a concurrent observation and interview in the walk-in refrigerator starting at 8:50 a.m., several covered casseroles were on a rack dated 10/9/22. SC confirmed the observation and stated the casseroles were Moussaka, an eggplant beef casserole. SC stated to make the casserole he cooks the ground beef, cooks the eggplant, and then assembles the casserole and puts in the refrigerator. The casserole was for lunch 10/11/22. During a concurrent interview and record review of Food Cooling Temperature Log, dated August 2022, on 10/10/22 at 9:31 a.m., SC stated this is the cooling log for October 2022, they used the wrong form. The log had two entries Roas Beef and Potato Salad. Director of Dining Services (DDS) stated while looking at cool down log the Roas beef written on cool down log is the beef for the moussaka. She confirmed no date on log for the Roast beef. She further confirmed the cooked eggplant and assembled casserole was not on the cool down log saying cooked vegetables cool fast, so they do not need to be monitored for cool down. According to 2017 Food and Drug Administration (FDA) Food Code, Chapter 1-2 Definitions, Time/temperature control for safety food includes .a plant food that is heat-treated. During a concurrent interview and record review of Food Cooling Temperature Log, dated August 2022, on 10/13/22 starting at 1:35 p.m., RD confirmed the only part of the moussaka on the cool down log was the beef. RD stated she would expect to see the entire moussaka casserole itself on cool down log, instead of just the meat, the whole casserole should be monitored for cool down. The cooked eggplant should have been monitored for cool down since it is cooked vegetable. During a review of the facility's policy and procedure (P&P) titled Quick Chill Service & Storage, dated January 1, 2020, the P&P indicated, Establish Control Procedures for effective record keeping documenting safe cool down and storage of hot food, Cooked potentially hazardous food may be rapidly cooled from 135 ºF to 70 ºF within a 2-hour period. Food can then continue to be cooled from 70 ºF down to 41 ºF within an additional 4-hour period. 2. During a concurrent observation and interview on 10/10/22, at 9:55 a.m., multiple small red (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 16 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm plastic Fruit cups and blue mugs were stored upside down on trays under the preparation table in salad preparation area. Two of the red cups had white rings inside. RD stated they are used as juice cup and for thickened juice. When a blue mug was wiped inside with finger, a flaky white substance came off with the presence of the DDS and the RD. RD confirmed they were stored clean for use. DDS confirmed they should have clean and should have thrown out if not cleanable. Residents Affected - Many During a concurrent observation and interview on 10/10/22, at 10:06 a.m., there were three more red bowls with white ring inside. Another blue mug scraped with fingers and white color residue came off which was confirmed by RD. DDS stated maybe thickener residue. Approximately 16 blue mugs had residue inside. Three red mugs and 11 red bowls all with residue inside. There were approximately 20 bowls/mugs per tray and approximately 9 trays. RD and DDS confirmed the observation. During a review of the facility's policy and procedure (P&P) titled Sanitation - regulation Dietetic ServicesSanitation, dated January 1, 2020, the P& P indicated , counters, shelves and equipment shall be kept clean , Plastic ware, imported, and glassware that cannot be sanitized or are hazardous because of chips, cracks, or loss of gaze shall be discarded. 3. During an observation on 10/11/22 at 9:18 a.m., inside the kitchen, the meat slicer was covered with a black plastic bag. Upon inspection, the slicer had a red piece of dried material on the slicer blade, had dried yellowish particles near slicing blade, and a sticky substance was able to be wiped off. During an interview at that time, RD verified that the meat slicer was stored clean if it was covered, it was not clean at that time, and should be stored clean after each use. During a review of the facility's policy and procedure (P&P) titled Electronic Equipment (Blender, Chipper, Grinder, Mixer, Slicer) dated January 1, 2020, indicated the frequency after each use Pay special attention to cleaning the corners, handles and hidden areas. During a review of the facility's policy and procedure (P&P) titled Sanitation - regulation Dietetic ServicesSanitation, dated January 1, 2020, the P& P indicated all utensil, counters, shelves and equipment shall be kept clean. 4. During an observation on 10/11/22 at 9:18 a.m., in the kitchen, the can opener had red particle on blade, base has black particle build-up that can wipe off, and residue around cutting blade. During an interview at that time, RD verified the observation and stated the can opener needs daily cleaning, should have been clean and ready to use. During a review of the facility's policy and procedure (P&P) titled Can Opener & Base, dated January 1, 2020, frequency indicated after each meal, procedures: wash the shank of the can opener by putting through the dish machine, wash and scrub the base with a brush and detergent solution; Clean and sanitize the can opener at least daily to prevent the growth of microorganisms or accumulated food. 5.a. During a concurrent observation and interview on 10/10/22 at 8:50 a.m., with the SC and RD inside the walk-in refrigerator, there were eight vacuum sealed flat iron steaks with delivery date of 10/4/22. No use by date was on the packaging. SC stated the meat comes in fresh and when it turns brown or green or changes color that's how he knows it has gone bad and it should have been discarded. RD stated she was unsure how long could have been in refrigerator and should have been check. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 17 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many b. During a concurrent observation and interview on 10/10/22, at 8:50 a.m., with the SC and RD inside the walk-in refrigerator, there were two boxes of frozen turkey thawing on the bottom shelf. There were no dates on the box. RD confirmed the observation and said there should have been a pull date on it when staff took it out of the freezer. During an interview on 10/13/22 at 1:35 p.m., with the RD inside her office, she stated that it was not correct to use color change of meat to determine whether it was good to use and should have a use-by date on all foods in the refrigerator. RD further confirmed when frozen meat was put in the refrigerator to thaw, it should have been dated when it was taken out of the freezer. During a review of the facility's policy and procedure (P&P) titled Storage & Inventory - General Procedure, dated January 1, 2020, the P & P indicated, All prepared foods and foods not in original containers must be COVERED, LABELED and DATED. 6a. During a concurrent observation and interview on 10/10/22 at 9:52 a.m., a metal 3 drawer cabinet with serving utensils inside, had brownish sticky substance along the three drawer edges. DDS confirmed the observation and should have been cleaned weekly. b. During a concurrent observation and interview on 10/10/22 at 8:35 a.m., in the dry storeroom with RD, masteca mix (a dry powder for making tortillas) container was sticky with residue build-up. RD confirmed the observation. During a concurrent observation and interview on 10/10/22 at 9:45 a.m., three white wheeled containers of dry parboiled rice, oats, and breadcrumbs under a food preparation table had a dried green material, had brownish smudges, and was sticky to touch. DDS confirmed they are a little dirty and they are cleaned weekly by kitchen staff. During an interview on 10/13/22 01:35 p.m., RD stated food bins for dry goods should have been clean at all times. During a review of the facility's policy and procedure (P&P) titled Sanitation - regulation Dietetic ServicesSanitation, dated January 1, 2020, the P& P indicated all utensil, counters, shelves and equipment shall be kept clean. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 18 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the proper disposal of garbage in the dumpster container when it was not properly contained, overflowing, and left open. This failure had the potential for a hazardous environment for the residents and staff due to possible harborage and feeding of pest. Residents Affected - Some Findings: During a concurrent observation and interview on 10/11/22, at 10:57 a.m., at the garbage building outside the facility had two dumpsters, one was inside the covered garbage disposal site located outside by the facility's parking lot near the kitchen back entrance. The other dumpster was outside and open about three inches with trash bags sticking out. Registered Dietitian (RD) confirmed the observation, lid was not completely shut. During a concurrent observation and interview on 10/11/22, at 11:01 a.m., with the Maintenance Manager (MM), the MM verified the observation stating the garbage was overflowing and garbage pickup was every Monday, Wednesday, and Friday. The dumpster should have been inside the garbage building and should have been closed and not overflowing. Review of the facility's policy titled Dispose of garbage and refuse properly dated January 1, 2020 , indicated Proper storage and disposal of garbage and refuse will be initiated to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents, indicated Outside receptacles must be constructed with tight -fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Outside garbage receptacles will not be overloaded with lids open. Lids should remain closed tight at all times, All the garbage receptacles shall be kept closed at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 19 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 6. During a medication pass observation on 10/11/22 at 4:45 p.m., licensed vocational nurse F (LVN F) washed her hands, put on gloves, injected two units of Admelog (insulin which can be used to help patients with diabetes control their blood sugar) to Resident 231. LVN F removed the gloves, threw the used syringe into the sharp bin and the gloves in the trash can, then opened the Medication Administration Record (MAR) binder and signed the MAR without washing or sanitizing her hands. Residents Affected - Some During a medication pass observation on 10/11/22 at 5:07 p.m., after administering glipizide (used to treat high blood sugar) 5 milligrams (mg, a metric unit of mass) 1 tablet and Preservision Areds 2 (a supplement that can help slow down vision loss) 1 capsule to Resident 231, LVN F put on gloves and administered dorzolamine (eye drops medication) 2 percent (%, unit of measurement) one drop to Resident 231's left eye without washing her hands. Then LVN F removed the gloves, threw used medication cup and gloves into the trash can, opened the medication cart, returned the box of dorzolamine to the medication cart, opened the MAR binder, and sign the MAR without washing or sanitizing her hands. During an interview with LVN F on 10/11/22 at 5:28 p.m., LVN F stated she should have wash her hands before she administered dorzolamine 2% to Resident 231's left eye, and she should have wash or sanitize her hands after she administered medication to the resident. Review of the facility's policy, Medication Administration - General Guidelines, dated 1/2021, indicated Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, parenteral, enteral, rectal, and vaginal medications. Hands are washed with soap and water again after administration and with any resident contact. 7. Review of Resident 5's physician order, dated 4/16/22, indicated she had an order for licensed nurse may suction oral secretions as needed for increased oral secretions. During an observation and interview with licensed vocational nurse A (LVN A) on 10/10/22 at 9:17 a.m., Resident 5's yankuer, suction tubing, and canister had oral secretion inside and were undated. LVN A stated Resident 5's yankuer, suction tubing, and canister should have been dated. During an interview with the infection preventionist (IP) on 10/14/22 at 4:05 p.m., she stated Resident 5's suction kit should have been changed after each use. Review of the facility's policy, Suction Equipment, dated 8/2020, indicated The following procedure to clean suction machines after each shift when used by a single resident and replace entire suction kit, daily and as needed. Replace suction catheter after each use. Review of Resident 9's physician order, dated 9/23/22, indicated she had an order for oxygen at one liter (L, a metric unit of volume) per minute via nasal cannula continuously for hypoxia (low levels of oxygen in the body tissues). During an observation with licensed vocational nurse A (LVN A) on 10/10/22 at 8:58 a.m., Resident 9 was on oxygen, and her nasal cannula was undated. During an interview with the director of staff development/infection preventionist (DSD/ IP) on 10/13/22 at 9:26 a.m., she stated nasal cannula tubing should have been dated and it should have been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 20 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm replaced. She further stated monitoring should have been documented every shift to describe appearance of oxygen tubing. During an interview with the director of nursing (DON) on 10/14/22 at 8:50 a.m., she stated oxygen tubing should have been dated and documented when the tubing should be replaced. Residents Affected - Some 9. During an initial tour of the facility on 10/10/22 at 9:11 a.m., Resident 229's used facial mask was exposed and hang at the back of his wheelchair handle. During a concurrent observation and interview on 10/10/22 at 9:12 a.m., with the infection preventionist (IP), she acknowledged the above observation and stated used facial mask should had been disposed by the facility staff in the garbage to prevent the resident reusing the facial mask and to prevent from the spread of infection. Based on observation, interview and record review, the facility failed to ensure effective infection control process when: 1. An incentive spirometer's (I.S. medical device to improve lung function) hose was touching the table surface; 2. A dirty oxygen concentrator (medical device for oxygen therapy) was stored in the clean utility room; 3. Used hand sanitizing wipes were left on the dining table accessible to resident; 4. An opened dirty laundry bag was exposed on top of a dirty linen cart; 5. A nasal cannula tubing (device used to deliver oxygen to a person) did not have a date of placement and monitoring sheet; 6. Licensed Vocational Nurse F (LVN F) did not wash her hands before administering the eye drop to Resident 231, and LVN F did not wash or sanitize her hands after administering medication to Resident 231; 7. Resident 5's yankuer (suction tip), suction tubing, and canister (container for storing) had oral secretion inside, and they were not changed and undated; 8. Resient 9's nasal cannula was undated and was not monitored; and 9. Resident 229's used facial mask was exposed and hang at the back of his wheelchair handle. These failures had the potential to result in transmission of infection in the facility. Findings: 1. During an observation on 10/10/22 at 10:01 a.m. inside Resident 28'S room. His I.S. mouth hose was touching the table surface. During a concurrent observation and interview with infection preventionist (IP) on 10/10/22 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 21 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 10:02 a.m., observed inside Resident 28's room. IP observed the I.S. hose was touching the table surface. She further stated the IS hose should have not touched the table surface and the I.S. should have been stored inside a clear bag when not in use to prevent contamination. During an interview with director of nursing (DON) on 10/14/22 at 8:28 a.m., she stated the I.S. should have been kept inside a clean bag to avoid contamination of the mouthpiece used by the resident. Review of Centers for Disease Control and Prevention (CDC) policy titled Respiratory Health Spirometry Procedures Manual) dated 1/2008, indicated All hoses used or unused will be placed in a clear container. 2. During a concurrent observation and interview with central supply designee (CSD) on 10/10/22 at 10:11 a.m., inside the clean utility room. An uncovered oxygen concentrator was observed inside the clean utility room. The CSD stated items not covered with plastic were dirty. DSD further acknowledged the oxygen concentrator was dirty and should have not been inside the clean utility room. During an interview with DON on 10/14/22 at 8:29 a.m., she stated resident care items should have been cleaned and properly disinfected before storage in the clean utility room. Review of the facility's policy titled Disinfection of Resident Care Items dated 7/21, the policy indicated Medical equipment (poles, oxygen concentrators.) would have been removed from residents rooms, taken to dirty utility room for full cleaning, and disinfection by housekeeping staff. Once cleaned, it was then moved to a clean closet or clean utility room. 3. During an observation on 10/10/22 at 11:34 a.m. in the dining area. CNA C wiped the hands of Resident 13 with sanitizing wipes. CNA C left the used sanitizing wipes on the dining table accessible to the resident. During an interview with CNA C on 10/10/22 at 11:35 a.m. she acknowledged the used sanitizing wipes should have been thrown away in the trash to avoid contamination. During an interview with DON on 10/14/22 at 8:39 a.m. The DON stated the sanitizing wipes used to clean hands should have been thrown away. A review of CDC's policy titled Cleaning and Disinfecting Workplaces and Community Settings dated 10/4/22, it indicated Any disposable items that have been in direct contact with skin should have been thrown away in the dedicated trash can. 4. During a concurrent observation and interview with Licensed Vocational Nurse A (LVN A) on 10/11/22 at 9:32 a.m., an opened dirty laundry bag was placed on top of a dirty laundry cart. LVN A acknowledged the dirty laundry bag should have been closed and should have been inside the dirty linen cart to avoid contamination. During an interview with IP on 10/11/22 at 9:33 a.m., she stated dirty laundry bags should have been closed and should have not placed on top of a dirty linen cart. During an interview with DON on 10/14/22 at 8:30 a.m., she stated dirty laundry bags should have been closed and dirty laundry bags should have been placed inside the dirty linen container. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 22 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's policy titled Procedure for Laundry Sanitation (undated). It indicated Soiled linens should have been placed in a soiled linen container. Plastic can liners should have been used to line soiled linen containers. 5. Review of Resident 22's physician orders indicated continuous oxygen at 2 L/min (liters per minute, unit of measurement). During an initial observation on 10/10/22 at 9:15 a.m., inside Resident 22's room. Resident 22's nasal cannula did not have a date of placement. During a follow up observation and interview with Licensed Vocational Nurse B (LVN B) on 10/10/22 at 9:24 a.m. inside Resident 22's room. LVN B acknowledged the above observation. She further stated there was no written monitoring for the description of nasal cannula tubing. During an interview with the DSD/ IP on 10/13/22 at 9:26 a.m., she stated nasal cannula tubing should have been dated. She further stated monitoring should have been documented every shift to describe appearance of oxygen tubing. During an interview with DON on 10/14/22 at 8:50 a.m., she stated oxygen tubing should have been dated and documented when the tubing should have been replaced. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 23 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the environment was free of pests as evidenced by flying insects seen near the kitchen drains and ant on the kitchen wall near the freezer. Residents Affected - Some This failure to maintain an effective pest control program had the potential to cause a health hazard to the residents and staff eating food from the kitchen. Findings: During a concurrent observation and interview, on 10/10/22 at 08:50 a.m., noted one ant in the wall crawling near the freezer wall which verified by the Registered Dietitian (RD). During a concurrent observation and interview on 10/10/22 at 09:47 a.m., a black small flying insect was in the kitchen sink floor drain area with food particles in the strainer on the top of the kitchen drain. Registered Dietitian (RD) and Director of Dining Services (DDS) confirmed the observation. DDS further stated the sink drains are cleaned nightly and she would expect it to be emptied now. During a concurrent observation and interview on 10/10/22 at 09:49 a.m., three black small insects (one flying, two crawling) were around and in the kitchen floor drain in the salad preparation area; the RD and DDS verified the observation. DDS further stated the floor drain is cleaned by maintenance but wasn't sure how often. During a concurrent observation and interview on 10/10/22 at 10:06 a.m., a fly was flying around our heads in the kitchen near clean cups and mugs. RD and DDS confirmed the observation. During a concurrent observation and interview on 10/11/22 at 10:40 a.m., a fly was flying around near where food was being prepared; RD confirmed the observation. During a concurrent interview and record review, on 10/11/22 at 09:43 a.m., with Maintenance Manager (MM) he confirmed that the kitchen drains are not on his weekly checklist. A review of facility document titled Kitchen PM checklist, dated October 2022 indicated kitchen drains are not on the list. During an interview with DDS on 10/13/22 at 2: 27 p.m., DDS stated once staff are done preparing food, the kitchen floor drain strainer should be emptied after each use. DDS indicated she needs to do in-service to the kitchen staff on keeping up with the cleaning. During a review of the facility's policy and procedure (P&P) titled Pest Control, dated January 1, 2020, the P& P indicated for Appropriate action will be taken to eliminate any reported pest situation in the department. During a review of facility's pest invoice titled Pest Elimination dated from 5/5/22, 6/02/22, 7/7/22, 8/04/22, 9/01/22, and 10/06/22 indicated Inspected for pest activity , sprayed the exterior for ants /roaches. According to the Food and Drug Administration (FDA) Food Code 2017, Section 6-501.111 and annex, Controlling Pests, The premises shall be maintained free of insects, rodents, and other pests and Insects and other pests are capable of transmitting disease to humans by contaminating food and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 24 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny View Manor 22445 Cupertino Road Cupertino, CA 95014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 25 of 25