Health inspection·January 12, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure care and services were provided to meet the professional standards of practice for one of five sampled residents (Residents 233) when registered nurse C (RN C ) did not shake the Med Plus (nutritional supplement) as directed prior to pouring in the medication cup; the Med Plus was not dated when opened; and RN C provided a wrong consistency of Med Plus to Resident 233, nectar thick consistency (liquids that are easily pourable and are comparable to heavy syrup found in canned fruit) instead of thin liquids as diet ordered. Residents Affected - Few These failures had the potential to jeopardize the health and safety of the residents. Findings: 1a. Review of Resident 233's face sheet (a document that gives a patient's information at a quick glance), dated 12/27/2023, indicated Resident 233 was admitted to the facility with diagnoses including hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (weakness or the inability to move on one side of the body), and dysphagia (difficulty swallowing). During medication administration observation on 1/9/2024 at 4:12 p.m., licensed vocational nurse D (LVN D) took out an opened Med Plus from the resident's refrigerator in the dining room and handed it to RN C. RN C poured 4 ounces (oz - unit of weight) of Med Plus to a cup without shaking it. At 4:30 p.m., RN C handed the cup of Med Plus to Resident 233. Resident 233 tried to drink it, but the Med Plus was thick, and Resident 233 had a hard time drinking. RN C provided a straw to help Resident 233 in drinking the Med Plus. It took about a minute until Resident 233 was able to drink the Med Plus using a straw. During an interview with RN C on 1/9/2024 at 4:40 p.m., RN C confirmed she did not shake the Med Plus prior to pouring in a cup. 1b. During a concurrent interview with LVN D and director of nursing (DON) on 1/9/2024 at 4:41 p.m., both licensed nurses stated the Med Plus should be dated when opened. LVN D further stated the kitchen staff should have provided a date opened sticker for nurses to label. Review of the Med Plus box label indicated, DIRECTIONS: .Shake well. Twist cap open and pour .STORAGE AND HANDLING: .Refrigerate after opening and use within 3 days. Additional review of the Med Plus box label indicated, Mildly Thick Nectar Consistency. Review of the facility's policy and procedure titled, Medication Administration: General Guidelines, dated 01/23, indicated, b. The nurse shall place a 'date opened' sticker .if one is not provided by the dispensing pharmacy and enter the date opened. 1c. Review of Resident 233's physician's telephone order dated 1/2/2024, indicated, Diet upgrade to mechanical soft chopped/thin. During a concurrent interview with DON and registered dietitian (RD) on 1/12/2024 at 10:40 a.m., RD confirmed the facility only had a nectar thickened Med Plus. RD agreed the doctor's order for Resident 233's liquid consistency was thin liquids and the Med Plus provided should have been thin consistency. DON agreed the doctor's order for Resident 233's fluid consistency was not followed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 2 of 14 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 01/12/2024 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 0658 Review of the facility's policy and procedure titled, Physician Orders, Noting Of, date revised February 2009, indicated, The nurse shall verify each order for completeness, clarity, appropriateness . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 3 of 14 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 01/12/2024 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide care and services for effective communication when a facility did not provide language assistance or other communication aid to two of three sampled residents with language barrier (speaking in foreign language) (Residents 83 and 4). Residents Affected - Few This failure had the potential to affect the psychosocial well-being of these residents and a decline in their activities of daily living. Findings: 1. During a concurrent observation and interview on 1/8/2024 at 9:08 a.m., Resident 83 was sitting up on a wheelchair and the certified nursing assistant F (CNA F) was also inside the room. CNA F stated Resident 83 was Mandarin speaking only. There was no communication binder/board or descriptive pictures observed inside the room. During a follow up observation on 1/8/2024 at 11:24 a.m., inside Resident 83's room, there were no communication binder/board or descriptive pictures on Resident 83's bedside drawers. Another observation on 1/9/2024 at 9:28 a.m., inside Resident 83's room, there was no on-site communication binder/board or descriptive pictures inside the room. During an interview with registered nurse E (RN E) on 1/9/2024 at 3:14 p.m., RN E confirmed he was the nurse assigned to care for Resident 83. RN E stated he used a pictured communication sheet to communicate with Resident 83. RN E confirmed the pictured communication sheet were not inside Resident 83's room. RN E tried to look for the pictured communication sheet at the nurse station and found 2 pages. Review of Resident 83's care plan titled, Communication, dated 1/11/2024, indicated Resident 83 had language barrier and his primary language was Mandarin. The Communication care plan interventions indicated to, Use alphabet communication board .Communicate using descriptive pictures to identify care needs. 2. Review of Resident 4's Quarterly, Minimum Data Set (MDS, an assessment tool) dated 12/21/2023, it indicated Resident 4's preferred language was Mandarin and she wanted or needed an interpreter to communicate with a doctor or health care staff. Review of Resident 4's care plan titled, Communication, dated 11/21/23, indicated Resident 4 had language barrier and her primary language was Mandarin. The Communication care plan interventions indicated to, Use alphabet communication board .Communicate using descriptive pictures to identify care needs. During an initial pool observation on 1/8/2024 at 9:28 a.m., Resident 4 was in bed and spoke Mandarin to this surveyor. There was no communication board/binder or descriptive pictures inside Resident 4's room. During another observation inside Resident 4's room on 1/9/2024 at 9:28 a.m., there was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 4 of 14 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 01/12/2024 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 0676 communication board/binder or descriptive pictures inside the room and on Resident 4's bedside drawers. Level of Harm - Minimal harm or potential for actual harm During an interview with registered nurse E (RN E) on 1/9/2024 at 3:14 p.m., RN E confirmed he was the nurse assigned to care for Resident 4. RN E stated he used a pictured communication sheet to communicate with Resident 4. RN E confirmed the pictured communication sheet were not inside Resident 4's room. RN E tried to look for the pictured communication sheet at the nurse station and found 2 pages. Residents Affected - Few During an interview with CNA F on 1/10/2024 at 2:00 p.m., CNA F stated she was not aware about the communication board/binder or descriptive pictures they could use to communicate to residents with language barrier. During an interview with social services director (SSD) on 1/11/2024 at 8:30 a.m., SSD stated she had a link in her computer regarding different languages. SSD further stated she would print out the appropriate language communication cue cards and leave them at residents' bedside for staff to use. SSD confirmed it is important to have a communication cue card inside residents' room for staff to be able to communicate to residents who had language barrier. During an interview with the director of staff development (DSD) on 1/11/2024 at 10:55 a.m., DSD stated SSD should prepare the communication board or cue cards upon resident's admission. DSD further stated the communication board or cue cards should be placed inside the resident's room. During a review of the facility's policy and procedure titled, Communication Assistance, date revised November 2016, indicated, Alternate methods for communication will be provided to assist with communication needs between the resident and staff .The facility will make arrangements for interpreters or alternate means of communication, such as pictures .to enhance communication between the resident and staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 5 of 14 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 01/12/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 16) remained free from accident hazards due to the use of bed rail (side rail) when Resident 16 had the left upper bed rail raised up while in bed without bed rail assessment, physician's order and care plan. This failure had the potential to put Resident 16 at risk for entrapment and serious injury. Findings: Review of Resident 16's face sheet (a document that gives a patient's information at a quick glance), last updated 12/21/2023, indicated Resident 16 was admitted to the facility with diagnoses including encounter for palliative care ( a specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness), Alzheimer's disease ( a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and adult failure to thrive (when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). Review of Resident 16's Admission, minimum data set (MDS, an assessment tool), dated 12/13/2023, it indicated Resident 16 required substantial/maximal assistance (staff does MORE THAN HALF the effort. Staff lifts or holds trunk or limbs and provides more than half the effort) with bed mobility and transfer. During an initial pool observation on 1/8/2024 at 9:07 a.m., Resident 16 was lying in bed, asleep, right side of bed was against the wall and the left upper bed rail was raised up. During a follow up observation on 1/9/2024 at 9:26 a.m., Resident 16 was lying in bed, non-coherent, and with left upper bed rail raised up. During a concurrent interview and record review with the minimum data set nurse (MDSN) on 1/11/2024 at 1:20 p.m., MDSN reviewed Resident 16's clinical records. MDSN stated Resident 16's short term and long-term memory was not okay. MDSN confirmed there was no bed rail/side rail assessment, no physician's order for bed rail use and no care plan developed. MDSN stated charge nurses were responsible for initiation of bed rail assessment upon residents' admission, obtained physician's order and bed rail consent and developed care plan. During an interview with the director of nursing (DON) on 1/11/2024 at 1:30 p.m., DON stated there should be a bed rail assessment, physician's order, consent and care planned prior to use of bed rail. During a review of the facility's policy and procedure titled, Side Rails/Assist Bar, dated April 2017, indicated, 1. Bed rails/assist bars should be in the down position and only used as an assistive device during turning and transfers .If it is determined that a bed rail/assist bar is the best alternative, the following requirements must be met: Discuss any concerns or potential safety risks with resident of resident's representative; The physician must be notified to give informed consent to the resident or resident representative; .Care plan the need for use of the bed rail/assist bar. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 6 of 14 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 01/12/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure a safe administration of medication and accurate accountability of controlled medications (those with high potential for abuse or addiction) when: 1. Registered nurse E (RN E) left the medication at resident's overbed table without ensuring Resident 136 had swallowed the solution. This failure had the potential for resident not taking the medications or having swallowing difficulty or choking without the nurse present for immediate help; and 2. Random controlled medication use audits for 2 out of 5 residents (Residents 135 and 8) did not reconcile. Two medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented in the Medication Administration Record (MAR) and two medications were signed out of the CDR, wasted with a witnessed nurse but was documented given in the MAR. There was a total of 4 controlled medications unaccounted for. This failure had the potential for misuse or abuse of controlled medications. Findings: 1. During a medication administration observation on 1/10/2024 at 9:50 a.m., RN E prepared and administered Resident 136 routine medications and left one cup of Cholestyramine oral solution (a medication used to treat high cholesterol) on Resident 136 overbed table. RN E stated she will take that later. During a follow up concurrent observation and interview with Resident 136 and RN E on 1/10/2024 at 12:43 p.m., Resident 136 was sitting up on her wheelchair eating lunch inside her room, with overbed table in front of her. The cup of Cholestyramine oral solution was still on the overbed table and was not even consumed. Resident 136 stated she did not know what it was. RN E stated he should have offered the medication again and should have not left the medication at bedside. During an interview with the director of nursing (DON) on 1/12/2024 at 10:38 a.m., DON stated medication should never be left alone at resident's bedside. During a review of the facility's policy and procedure titled, Medication Administration: General Guidelines, dated 01/23, indicated, 4. Medications are to be administered at the time they are prepared .20. The resident is always observed after administration to ensure that the dose was completely ingested. 2. The Controlled Drug Records (CDRs) for five random residents receiving controlled medications were requested for review during the survey on 1/9/2024 at 4:30 p.m. a. Resident 136 was a hospice (a program focuses on the care, comfort, and quality of life of a person with serious illness who is approaching the end of life) resident and had a physician's order dated 12/29/2023, for morphine sulfate (a controlled medication for pain and for comfortable breathing) 20 milligrams (mg, unit of measurement)/milliliters (ml, metric unit of volume), 0.3 ml by mouth every 8 hours around the clock (ATC) for comfort breathing. During a concurrent interview and record review with the director of nursing (DON) on 1/11/2024 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 7 of 14 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 01/12/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm 1:49 p.m., DON stated nurses should sign their name in CDR once a narcotic was pulled out of the narcotic box, and they should document in the residents' MAR once given. DON reviewed Resident 136 CDR for morphine sulfate and the 1/2024 MAR. DON confirmed morphine sulfate 0.3 ml was taken out of the narcotic box and signed out by nurses in CDR on 1/6/2024 at 2 p.m. and 1/9/2024 at 6 a.m. but were never signed as administered in the MAR. DON verified two doses of morphine sulfate were not accounted for. Residents Affected - Few b. Resident 8 had a physician's order dated 12/15/2023 for codeine sulfate (a controlled medication for pain) 30 mg, half tablet three times a day, prior to transfer and after lunch. During a concurrent interview and record review with the DON on 1/12/2024 at 9:39 a.m., a review of Resident 8's CDR for codeine sulfate and the 12/2023 MAR reflected the nursing staff signed out the medication in the CDR and wasted it with another nurse as a witness on 12/18/2023 for the 6 p.m. dose, but documented administered in the MAR. DON confirmed the medication was wasted and should have been documented as not administered by a circle marked around nurse's initial in the MAR. At 10:19 a.m., another review of Resident 8's CDR for codeine sulfate and the 1/2024 MAR reflected the nursing staff signed out the medication in the CDR and wasted it with another nurse on 1/1/2024 for the 1 p.m. dose, but documented administered in the MAR. DON stated the nurse should have marked a circle around his initial and documented at the back of the MAR to indicate the reason why the medication was not administered. During a concurrent interview and record review on 1/12/2024 at 10:22 a.m., licensed vocational nurse H (LVN H) reviewed Resident 8's CDR and the 1/2024 MAR. LVN H confirmed she was the one who witnessed with the day shift nurse who pulled out the codeine sulfate from the narcotic box. LVN H stated they wasted the medication because it fell on the floor. LVN H further stated the medication was not given to the resident and the nurse should have circled his initial and documented at the back of the MAR, the reason why it was not given. During a review of the facility's policy and procedure titled, Medication Administration: Controlled Substances, dated 01/23, indicated, 4. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from the controlled storage: a. Date and time of administration; b. Amount administered; c. Signature of the nurse administering the dose. 5. Administer the controlled medication and document dose administration on the MAR. Another review of the facility's policy and procedure titled, Medication Administration: General Guidelines, dated 01/23, indicated, 2. If a dose of regularly scheduled medication is withheld, refused, or given at other than the schedule time .the MAR/eMAR must be appropriately documented and explanatory notation/documentation made . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 8 of 14 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 01/12/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all drugs and biologicals (therapeutic substance like a vaccine or drug) are labeled in accordance with professional standards, when expired Prostat (liquid protein supplement) bottles were found in the medication storage room. This failure could potentially compromise the health and safety of the residents. Findings: During a concurrent observation and interview with Minimum Data Set Nurse (MDSN) on [DATE] at 8:38 a.m., inside the facility's medication room, two bottles of Prostat were stored with labeled expiration date of [DATE]. MDSN stated it should have been discarded and not stored inside the medication room. MDSN also stated nurses and central supply staff were responsible for making sure medications stored were not expired. During an interview with the Director of Nursing (DON) on [DATE] at 8:33 a.m., DON stated the expired Prostat should not have been stored in the medication room. DON further stated all expired medication and biologicals should be discarded. During a review of the facility's policy and procedure (P&P) titled, Medication Storage, dated 1/23, the P&P indicated, Outdated, contaminated, discontinued or deteriorated medications .are immediately removed from the stock, disposed of according to procedures for medication disposal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 9 of 14 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 01/12/2024 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interview, and record review, the facility failed to provide the correct therapeutic diet (A therapeutic diet is a meal plan that controls the intake of certain foods and food consistency) to one of 41 sampled residents (Resident 4) as ordered by Resident 4's physician. This failure had the potential for Resident 4 to choke on foods not prepared in the correct consistency. Findings: During an observation on 1/9/24, at 10:35 a.m. in the kitchen, [NAME] A requested a mechanical soft ground meal for Resident 4 from [NAME] B. [NAME] A was given a regular consistency (whole meat, not ground) and placed it onto Resident 4's meal tray in the meal cart, then moved onto the next resident's tray. During an interview on 1/9/24, at 10:45 a.m., with [NAME] A, [NAME] A stated, I asked for a mechanical soft ground meat, but was given a regular meal consistency. I plated the regular meal consistency for Resident 4, and the meal ticket tray shows mechanical ground soft is needed, not regular. During an interview on 1/9/24, at 11 a.m., with Registered Dietician (RD), RD stated, Resident 4's meal order was updated this morning to puree, from mechanical soft. His meal was prepped to the wrong consistency meal based on the meal ticket, we did not update the meal ticket after the puree order was placed this morning. During a review of Resident 4's Physician Order, dated 9/22/23, the Order indicated, Diet, Regular, Consistency: Mechanical Soft, Ground Meats. During a review of Resident 4's Care Plan, dated 9/22/23, Care Plan indicated, Dietary Needs: mech soft ground-regular. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets & Use of Diet Manual dated 2020, the P&P indicated, It is the policy of the facility to provide therapeutic diets as prescribed by the physician and planned by the Registered Dietitian. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 10 of 14 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 01/12/2024 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 and sanitary conditions were met for food storage and preparation in the kitchen when: Residents Affected - Many 1. Produce was not labeled or dated in the walk-in refrigerator. 2. Hot foods were not kept at 135 degrees Fahrenheit during meal service tray line. These failures had the potential for all residents in the facility to be introduced to food borne illnesses. Findings: 1. During a concurrent observation and interview on 1/8/24, at 8:43 a.m., with Director of Dining Services (DDS) in the kitchen, eight raw whole honeydew melons were noted to be in a non-manufacturer hard plastic container in the walk-in refrigerator. No labels or dates were noted on honeydew melons or the container. Three bags of raw shredded carrots, 1 bag of whole raw radish, 2 bags of raw wedged carrots, and 2 bags of raw pre-cut celery were noted in one non-manufacturer hard plastic container with no labels or dates. DDS stated, the honeydews, carrots, radishes and celery all do not have a date or label on them. They should be labeled and dated when they arrive to the facility and are placed in the fridge. During a review of the facility's policy and procedure (P&P) titled, Dining Services Storage & Inventory dated 2020, the P&P indicated, All prepared foods and foods not in the original containers must be COVERED, LABELED, and DATED. 2. During a concurrent observation and interview on 1/9/24, at 11:25 a.m., with [NAME] A, in the kitchen, [NAME] A prepared a pureed meal tray for Resident 7's meal tray with the prescribed diet of pureed foods during meal service for lunch. [NAME] B placed the meal tray onto the dining cart and moved onto the next resident. [NAME] A checked the temperature of pureed foods kept under a warmer and not in the steam trays, the pureed vegetable temperature indicated 133 degrees Fahrenheit, the pureed rice indicated 133 degrees Fahrenheit, the pureed mashed potatoes indicated 115 degrees Fahrenheit. [NAME] A stated, all hot foods should be kept at 135 degrees Fahrenheit or higher. During a review of the facility's P&P titled, Dining Services Quick Chill Service & Storage dated 2020, the P&P indicated, b. During Service, hot foods must be maintained at 135 F (60 C) or above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 11 of 14 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 01/12/2024 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 Based on observation, interview and record review, the facility failed to implement infection control practices when: Residents Affected - Some 1. Certified Nursing Assistant F (CNA F) did not perform hand hygiene in between Resident 83's bed making task and glove changed; 2. Certified Nursing Assistant G (CNA G) did not perform hand hygiene in between serving food to residents (Residents 15, 184, 16 and 8) and when assisting two residents with meals (Residents 5 and 83); and 3. Registered Nurse C (RN C) did not perform hand hygiene in between medication administration task and glove changed (Residents 134 and 233). These failures had the potential to compromise resident's health and safety in the facility. Findings: 1. During an observation on 1/8/2024 at 9:15 a.m., inside Resident 83's room, CNA F donned (put on) a new pair of gloves without performing hand hygiene. CNA F removed Resident 83's dirty linens and placed them in a laundry bag. She removed her dirty gloves and stepped out of the room to get clean linens located at the hallway without performing hand hygiene. CNA F went back to Resident 83's room, donned a new pair of gloves, without hand hygiene and started to make Resident 83's bed. After bed making task, CNA F removed the used gloves, no hand hygiene performed and took the bag of dirty linens to the shower room. CNA F stepped out of the shower room, took a clean comforter, went back inside Resident 83's room, donned a new pair of gloves, without hand hygiene and placed the comforter on Resident 83's bed. CNA F removed her gloves, hand hygiene was not performed, took Resident 83's breakfast tray and dropped it to the meal cart. During a follow up interview with CNA F on 1/8/2024 at 9:26 a.m., CNA F stated, Oh yes, I should have sanitized my hands. CNA F confirmed she did not perform hand hygiene in between bed making task, before she donned a new pair of gloves, and after removal of gloves. During a concurrent interview with the facility's infection preventionist (IP) and director of staff development (DSD) on 1/11/2024 at 10:53 a.m., both IP and DSD agreed hand hygiene should have been done in between bed making tasks, before donning a new pair of gloves and after doffing (removal) of dirty gloves. 2a. During a meal observation on 1/8/2024 at 11:44 a.m., inside the dining room, CNA G served the meal tray to Resident 15: removed all the plastic wrappers and disposable lids in Resident 15's food and placed them on the plate cover, CNA G then went to throw away all the plastic wrappers and disposable lids to the trash bin under the sink. CNA G did not perform hand hygiene. She started to take another lunch tray from the cart and served it to Resident 184. CNA G touched Resident 184's utensils, poured cranberry juice to a cup and threw away some trash. At 11:50, CNA G served Resident 16's food, did not perform hand hygiene after, adjusted her pants and started to serve Resident 8's food. 2b. During a meal assistance observation on 1/8/2024 at 11:54 a.m., inside the dining room, CNA G sat on a chair in between Resident 5 (located in CNA G's right side) and Resident 83 (located in CNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 12 of 14 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 01/12/2024 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 G's left side) to assist Resident 5 with lunch. CNA G started to scoop Resident 5's food using a spoon to feed her. While feeding Resident 5, CNA G was observed adjusted her face mask, positioned her eyeglasses, touched her hair, and continued to feed Resident 5. At 11:59, still no hand hygiene performed, CNA G helped Resident 83 in wiping his mouth with the used of his tablecloth. CNA G touched Resident 83's cup to offer him to drink, then continued to assist Resident 5, without hand hygiene. CNA G tried to assist Resident 83 with his food, touched his spoon and wiped his mouth again using his table cloth. During an interview with CNA G on 1/8/2024 at 2:31 p.m., CNA G confirmed this surveyor's meal observation. CNA G stated she made a mistake of not performing hand hygiene in between serving residents' lunch trays. CNA G further stated she should have washed her hands in between residents' feeding assistance to prevent cross contamination. CNA G agreed she should have avoided touching her face mask, eyeglasses, hair and even her pants in between dining room tasks. During a concurrent interview with the IP and DSD on 1/11/2024 at 10:39 a.m., both managers agreed hand hygiene should be performed in between serving and setting up resident's meal trays to prevent transmission of infection. Both managers stated hand hygiene should also be performed in between task or in between residents' meal assistance. During a review of the facility's policy and procedure titled, Hand Hygiene Program, dated August 2017, indicated, Hand hygiene is the most important way to prevent the spread of infection and prevents contamination of the resident's environment .Indications for performing hand hygiene: Before and after contact with resident or their environment; Before and after glove use; Before handling clean linen; After disposal of soiled linen; .Before and after preparing food (includes before eating or serving food to residents) .After touching items that are likely to be contaminated. 3. During medication administration observation on 1/9/2024 at 3:50 p.m., RN C went to the medication room to get the ondansetron (medication for nausea) in the emergency kit. At 3:54 p.m., RN C stepped out of the medication room and started to prepare Resident 134's routine and as needed medication without hand hygiene. At 3:57 p.m., RN C went back to the medication room to get metoclopramide (medication for nausea) and continued with Resident 134's medication preparation, still did not perform hand hygiene. At 4:07 p.m., RN C entered Resident 134's room and administered the medications to Resident 134, still no hand hygiene performed. During another medication administration observation on 1/9/2024 at 4:12 p.m., RN C went to Resident 233's room, donned a new pair of gloves without hand hygiene and checked Resident 233's blood pressure (the pressure of blood pushing against the wall of the arteries, which could be measured with the use of an equipment). RN C removed the gloves after checking Resident 233's blood pressure and started to prepare her medications. At 4:30 p.m., RN C donned another pair of gloves without hand hygiene and started to administer Resident 233's routine medications. RN C went out of the room, removed the gloves, and signed the medication administration record (MAR), without performing hand hygiene. During an interview with RN C at 4:40 p.m., RN C confirmed she did not perform hand hygiene in between medication administration task, in between residents, before donning gloves and after removal of gloves. During a concurrent interview with IP and DSD on 1/11/2024 at 10:49 p.m., both managers agreed nurses should performed hand hygiene in between medication administration task/residents and before donning and after removal of gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 13 of 14 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 01/12/2024 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 During review of the facility's policy and procedure titled, Medication Administration: General Guidelines, dated 01/23, indicated, Hands are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulations. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 14 of 14