Health inspection·April 18, 2024

F 0684 Level of Harm - Actual harm Residents Affected - Few extensor posturing (also called decerebrate posturing, an abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backward). Review of Resident 1's Occupational Therapy (OT) Progress Note, dated 12/8/23, indicated therapy treatment was well tolerated and there were no barriers impacting treatment. Review of Resident 1's PT Progress Note, dated 12/11/23, indicated Resident 1 was observed to be non-verbal and mostly not focusing. PT Progress Note further indicated barriers impacting treatment were decreased attention skills and the nurse on duty was made aware of Resident 1's signs and symptoms. Review of Resident 1's OT Progress Note, dated 12/11/23, indicated Resident 1 did not tolerate the therapy session and Resident 1's Glasgow coma scale was 9/15. OT Progress Note further indicated the nurse on duty was notified. Review of Resident 1's Nurse Progress Note, dated 12/11/23, indicated occupational therapy (OT) reported Resident 1 scored 9/15 on the Glasgow Coma Scale. Nurse Progress Note further indicated there was no documentation in Resident 1's clinical record that the physician was notified. Review of Resident 1's Speech Therapy (ST) Progress Note, dated 12/11/23, indicated Resident 1 had a change in condition per Speech Therapist (ST) observation and the Physical Therapist (PT) and Occupational Therapist (OT) report. ST Progress Note further indicated Resident 1 showed minimal receptiveness and verbalization. The ST Progress Note further indicated Resident 1's response to treatment had noticeably declined. ST Progress Note further indicated that the Speech Therapist recommended imaging (a type of test that makes detailed pictures of areas inside the body) consultation to rule out a Transient Ischemic Attack (TIA, short period of symptoms like those of a stroke) or CVA and consulted with the Charge Nurse regarding Resident 1's status. Review of Resident 1's Nurse Progress Note, dated 12/11/23, indicated Resident 1 was not communicating with PT and when Resident 1 was asked questions Resident 1 did not respond. There was no documentation in Resident 1's clinical record the physician was notified. Review of Resident 1's PT Progress Note, dated 12/13/23, indicated Resident 1 was non-verbal with mild to moderate spasticity (stiff or rigid muscles) noted on both of her lower extremities. PT Progress Note further indicated barriers impacting treatment were reduced level of alertness and increasing muscle tone. PT Progress Note further indicated nursing was made aware of Resident 1's signs and symptoms during the Interdisciplinary Team (IDT, a group of healthcare professionals who meet to discuss and plan patient care) Care Conference on 12/13/23. Review of Resident 1's IDT Care Conference Note, dated 12/13/23, indicated Resident 1 was not eating, had a lot of global extensor tone (Abnormal muscle tone, muscle tone is the resistance of a muscle to active or passive stretch, or the overall stiffness of the muscle) and limited ability to initiate motor movements (actions of the muscles). Review of Nurse Progress Note, dated 12/13/23, indicated Resident 1 was not verbalizing to the nurse and was not following directions during the passing of medication. Nurse Progress Note further indicated Resident 1 was not able to complete the PT session and there was no documentation in Resident 1's clinical record that the physician was notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 2 of 5 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 04/18/2024 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 0684 Level of Harm - Actual harm Residents Affected - Few Review of Resident 1's Nurse Progress Note, dated 12/14/23, indicated the physician was notified to see Resident 1 regarding therapy noted Resident 1 was non-verbal and had a Glasgow Coma Scale of 9/15 with extensor posturing (involuntary positioning of the arms when stimulated, a result of a severe brain injury). Progress Note further indicated when Resident 1 was admitted to the skilled nursing facility (SNF) Resident 1 was able to say a few words but was now non-verbal. Review of Resident 1's Physician's Progress Note, dated 12/14/23, indicated the physician was called to see Resident 1 for new changes. Progress Note indicated Resident 1 had clinically worsened with decreased responsiveness. Progress Note further indicated Resident 1 was no longer verbalizing, had possible new right-sided weakness, was unable to swallow medications and food, and had extensor posturing. Progress Note further indicated Resident 1's attending physician (AP) suspected an extension of the CVA (cerebrovascular accident, major worsening, or deterioration in neurological [relating to the nervous system] status following an initial stroke requiring medical attention). The Progress Note further indicated that Resident 1 was transferred to the emergency department (ED) by ambulance. Review of Resident 1's acute care hospital Emergency Department Progress Note, dated 12/14/23, indicated Resident 1 had been nonverbal for two days and was brought to the ED for not taking oral medications or talking. ED note further indicated Resident 1 was not following commands or talking with a left gaze preference (an abnormality of gaze that can be observed following an acute cerebral lesion, e.g., stroke) and right arm weakness. Review of Resident 1's acute care hospital History & Physical (H & P) dated, 12/14/23, indicated Resident 1 had a history of a recent stroke and was hospitalized for six days from 11/29/23 through 12/5/23, after falling in her bathroom two days prior at home. At discharge from the acute care hospital on [DATE], to the SNF (skilled nursing facility), Resident 1was able to follow commands and was talking in complete sentences. Subsequently, Resident 1 was then referred to the ED on 12/14/23, after her SNF staff noted Resident 1 was more lethargic (sluggish & lacking energy) and no longer speaking, with a left lateral gaze preference. Resident 1 was admitted to the Intensive Care Unit (ICU) for further evaluation and taken for a Computed Tomography Scan (CT, a diagnostic imaging procedure that can show whether you had a stroke). CT results showed worsening subdural stroke (also known as subdural hematoma, occurs when a blood vessel in the space between the skull and the brain [subdural space] is damaged) in addition to ischemic stroke (occurs when a blood clot blocks blood flow in your brain, versus hemorrhagic stroke is when a blood vessel in your brain ruptures). The H & P further indicated Resident 1 was not deemed a candidate for any intervention at the time of admission to the acute care hospital on [DATE] due to Resident 1's late presentation. It further indicated Resident 1's code status was changed to do not resuscitate (DNR, do not resuscitate or do not perform cardiopulmonary resuscitation [CPR, emergency lifesaving procedure] to restart the heart) and do not intubate (DNI, do not insert a breathing tube) due to Resident 1's chance of surviving being very low. Review of Resident 1's acute care hospital Hospitalist Progress Note dated, 12/17/23, indicated Resident 1 was unresponsive and not following commands at time of admission . Resident 1's Hospitalist Progress Note further indicated Resident 1 presented at the SNF with a 2-day history of progressive lethargy and altered level of consciousness and was found to have an acute chronic subdural hemorrhage (a pool of blood between the brain and its outermost covering) upon admission to the acute care hospital. Review of Resident 1's Hospital Discharge summary, dated [DATE], indicated Resident 1 did not show any neurologic improvement with no potential for any meaningful neurologic recovery after admission (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 3 of 5 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 04/18/2024 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 0684 and was ultimately placed on comfort care and expired in the acute care hospital on [DATE]. Level of Harm - Actual harm Review of Resident 1's Death Certificate indicated: date of death : 12/19/23 Immediate Cause: COMPLICATIONS OF TRAUMATIC SUBDURAL HEMMORRHAGE and Death Reported to Coroner? Yes. Residents Affected - Few During a telephone interview with Physical Therapist A (PT A), on 3/27/24 at 2:40 p.m., PT A stated that when she first saw Resident 1 on 12/8/23, Resident 1 was conversing, coherent and responding appropriately. PT A further stated that when she saw Resident 1 on 12/11/23, Resident 1 was no longer communicating and functionally Resident 1 was declining with upper extremity extensor posturing (involuntary extension of the upper extremities in response to external stimuli). PT A reported the signs and symptoms to the nurse on duty. During a telephone interview with Speech Therapist B (ST B), on 3/28/24, at 1:45 p.m., ST B stated that when she saw Resident 1 on 12/11/23, Resident 1 was non-responsive with a noted drastic decline in condition and she reported the change in condition to the nurse on duty. ST B further stated it is a nursing protocol to notify the doctor of a change in condition. During a telephone interview, on 4/5/24, at 3:56 p.m., Registered Nurse C (RN C) stated that staff usually let the doctor know if there has been a change in a resident's condition and the doctor will order the resident be transferred out to the hospital for further evaluation or treatment. RN C acknowledged that on 12/11/23 OT reported Resident 1 scored a 9/15 on the Glasgow Coma Scale. RN C also stated it was a change in condition. RN C further stated he does not remember if he reported it to the doctor. RN C acknowledged there was no documentation in Resident 1's clinical record that the change in condition was reported to the doctor. RN C further stated the doctor should have been notified. During a telephone interview with the Minimum Data Set Coordinator (MDSC), on 4/5/24 at 4:25 p.m., MDSC stated she assessed Resident 1 when Resident 1 was admitted to the facility. The MDSC further stated at that time Resident 1 was alert and responsive. The MDSC also stated at the IDT care conference on 12/13/23, therapy reported Resident 1 had a lot of global extensor tone (rigidity) and the MDSC stated that was a change in condition for Resident 1. The MDSC further stated it was something therapy had noted and first brought to her attention at the time of the IDT care conference. MDSC further stated she was not aware if anyone notified the doctor about the Resident 1's change in condition. The MDSC further stated she also did not notify the doctor and that the doctor should have been notified. During a telephone interview, on 4/12/24 at 11:15 a.m., the director of nursing (DON)stated that when there is a change in a resident's condition, staff usually notify the doctor by text message. The DON further stated that she first became aware of Resident 1's change in condition during the IDT Care Conference on 12/13/23. The DON further stated she expected that the MDSC would notify the resident's doctor. DON acknowledged that the doctor was not notified about the Resident 1's change in condition and that the doctor should have been notified. During a telephone interview, on 4/16/24, at 4:00 p.m., Resident 1's attending physician (AP) stated that when she saw Resident 1 on 12/8/23, Resident 1 was alert and talking intermittently. The AP further stated she was called to see Resident 1 six days later (12/14/23) and the PT pointed out Resident 1 had gone from a 14 on the Glasgow Coma Scale to a 9, had stopped taking her medications, had extensor posturing and was no longer verbal. The AP further stated she did not think she was notified of a change in condition prior to seeing Resident 1 on 12/14/23. The AP further stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555342 If continuation sheet Page 4 of 5 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 04/18/2024 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 0684 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete notified Resident 1's FM/DPOA and that Resident 1 had possibly extended her stroke (extension or worsening of a stroke following an initial stroke requiring medical attention). The AP further stated Resident 1's FM/DPOA said to send Resident 1 out to the ER (emergency room) for evaluation. Review of the facility's revised November 2016 policy Change in Resident Condition states that any sudden serious change in a resident's condition manifested by a marked change in physical or mental behavior, will be communicated to the physician with a request for a physician visit promptly and/or acute care evaluation. It further states that the resident/resident's representative will be notified that there has been a change in the resident's condition, and what steps are being taken. Event ID: Facility ID: 555342 If continuation sheet Page 5 of 5