Health inspection·November 8, 2021

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 ensure residents received the necessary care and services for seven of 41 sampled residents (Residents 12, 11, 45, 66, 7 and 8) when: Residents Affected - Some 1. Staff did not develop a personalized and resident-centered care plan, or document any follow-up treatment/skin reassessment when Resident 12 sustained a hematoma (a collection of blood, usually clotted, outside of a blood vessel that may occur because of an injury to the wall of a blood vessel) and cut on her right eyebrow. 2. Staff did not follow the physician's order to place floor/landing pad next to the bed when Resident 11 was in bed. 3. Staff did not follow the physician's order for bilateral heel floaters while in bed for Resident 45. 4. Licensed nurses did not follow the physician's orders for pain medication based on the residents' pain level for Residents 66 and 7. 5. Licensed nurses did not follow ordered parameters for blood pressure medication for Resident 8. These failures had the potential to affect the residents' care and could jeopardize their health and well-being. Findings: 1. During a record review and concurrent interview on 11/4/21 at 1:52 p.m., licensed vocational nurse H (LVN H) reviewed Resident 12's progress notes dated 9/25/21 that indicated she had an incident when she sustained a hematoma and cut on her right eyebrow after accidentally hitting the siderail during ADL (activities of daily living) care. LVN H confirmed there was no care plan developed and/or any follow-up skin treatment/reassessment documented. LVN H stated, whoever did the incident report should have done the care plan. A review of the undated policy and procedure on Comprehensive Assessments and the Care Delivery Process, indicated assessment and information collected, information analysis, and decision making leading to person-centered plan of care includes selecting and implementing interventions based on the results of the above. Monitor results and adjust interventions by periodically reviewing progress and adjusting treatments. 2. A review of Resident 11's Fall Risk Review dated 2/11/21, 5/18/1 and 8/17/21 indicated scores that indicated she was high risk for falls. The physician's order dated 2/11/21 included an order for floor/landing pad to be placed next to the bed when the resident is in bed every shift. Her care plan dated 5/18/21 and revised on 8/22/21 indicated she was high risk for falls related to poor safety awareness, impaired cognition and history of falling. During observations on 11/3/21 at 9:23 a.m., and on 11/5/21 at 9:24 a.m., while Resident 11 was in bed awake, there was no landing or floor pad seen on the floor next to her bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555790 If continuation sheet Page 2 of 18 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 555790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Crest Nursing and Rehabilitation Center 797 E Fremont Avenue Sunnyvale, CA 94087 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 Residents Affected - Some During an observation and concurrent interview on 11/8/21 at 9:15 a.m., while Resident 11 was in bed awake, licensed vocational nurse I (LVN 1) confirmed there was no landing or floor pad placed at the side of her bed. Upon review of Resident 11's physician's orders LVN 1 stated resident should have a landing pad when she was in bed. During an interview on 11/8/21 at 10:38 a.m., the director of staff development (DSD) stated Resident 11 needed the landing pad for safety and she already placed the pad after her attention was called to it. The DSD also stated staff should carry out doctor's orders. 3. A review of Resident 45's facesheet included diagnoses of abnormal posture, type 2 diabetis mellitus (a long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin), and heart failure (a heart condition that causes symptoms of shortness of breath, weakness, fatigue, and swelling of the legs, ankles, and feet). His physician's order dated 8/17/21 included bilateral heel floaters while in bed as tolerated. A review of Resident 45's Braden Scale For Predicting Pressure Sore Risk dated 9/7/21 indicated score of 12 or high risk for pressure ulcer. His care plan (CP) for risk for skin breakdown and further decline in skin integrity dated 8/17/21 and revised 10/6/21 included interventions float heels while in bed. The revised CP dated 11/3/21, Resident has potential/actual impairment to skin integrity , bil heels blanchable redness indicated approaches/tasks that included elevate heels off the bed. During observations on 11/3/21 at 2:00 p.m. and on 11/4/21 at 1:49 p.m., Resident 45 was seen in bed with no heel floaters applied. During an observation on 11/5/21 at 1:08 p.m., Resident 45 was in bed wearing socks, heels were touching the mattress, and licensed vocational nurse J (LVN J) assessed his heels and noted left heel redness. During the concurrent interview, LVN J confirmed Resident 45 did not have his heel floaters applied nor his heels were elevated with anything. LVN J stated heel floaters were purple boots that should be applied to the resident's heels to help prevent pressure ulcer/injury. LVN J reviewed Resident 45's physician's orders and confirmed there should be heel floaters applied when the resident was in bed. 4. A review of Resident 66's facesheet included diagnoses of specified fracture of right pubis (break of the ring of bones that connect your spine to the hips), right hip osteoarthritis (is the most common form of arthritis, inflammation of the joint, usually called degenerative joint disease or wear and tear arthritis), polyneuropathy (damage to multiple nerves outside of the brain and central nervous system that can cause pain, discomfort, and mobility difficulties) and, difficulty in walking. During an observation and concurrent interview on 11/5/21 at 10:05 a.m., Resident 66 who was sitting up in a wheelchair in her room stated, my pain is not good especially right hip, and, been painful for a while and pain still there. A review of Resident 66's physician's order dated 10/7/21 included Oxycodone-Acetaminophen (pain medication) 10-325 mg. (milligrams, unit of measurement) one tablet by mouth every 4 hours as needed for moderate pain 4-6/10 pain level and 2 tablets as needed for severe pain (7-10/10 pain level). The medication administration record (MAR) for October 2021 indicated staff administered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555790 If continuation sheet Page 3 of 18 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 555790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Crest Nursing and Rehabilitation Center 797 E Fremont Avenue Sunnyvale, CA 94087 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 Residents Affected - Some Oxycodone-Acetaminophen 10-325 mg one tablet for 7/10 pain level (severe pain) on 10/17/21 and 10/22/21 instead of two tablets; and administered two tablets for 2-5 pain level (moderate pain) instead of one tablet as per physician's order on 10/8/21, 10/17/21, 10/21/21, 10/24/21, 10/27/21 and 10/28/21. During an interview on 11/5/21 at 10:17 a.m., registered nurse K (RN K) stated Resident 66 was still in pain because she just had the right hip surgery and nurses should follow doctor's orders. Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated RNs should follow the physician orders for a medication regimen necessary to implement a treatment per the physician's order. 4a. Review of Resident 7's admission Record indicated he was readmitted to the facility on [DATE] with orthopedic (relating to the branch of medicine dealing with the correction of deformities of bones or muscles) aftercare diagnosis. Review of Resident 7's physician order indicated he had an order on 11/6/19 to monitor for presence of pain every shift using scale 0-10; 0 = no pain; 1-2 = least pain; 3-4 = mild pain; 5-6 = moderate pain; 7-8 = severe pain; 9-10 = very severe/horrible/worst pain. Resident 7 also had a physician order for Norco (used to treat pain) 5-325 milligrams (mg, a metric unit of mass) one tablet every 4 hours as needed for severe breakthrough pain, started on 11/30/2020. Review of Resident 7's Medication Administration Record (MAR), from 9/2021 to 11/2021, indicated licensed nurses administered Norco 5-325 mg to Resident 7 when he had pain level below 7 which was mild to moderate pain on 9/12/21, 9/16/21, 9/20/21, 9/24/21, 9/27/21, 9/28/21, 9/29/21, 10/3/21, 10/6/21, 10/7/21, 10/10/21, 10/11/21, 10/12/21, 10/13/21, 10/14/21, 10/17/21, 10/20/21, 10/21/21, 10/23/21, 10/26/21, 10/27/21, 10/31/21, 11/3/21, and 11/4/21. During an interview with the director of nursing (DON) on 11/5/21 at 4:15 p.m., she stated the severe pain level was 7-10. The DON reviewed Resident 7's 9/2021 to 11/2021 MARs and confirmed that licensed nurses administered Norco 5-325 mg to Resident 7 when he had pain level below 7 on 9/12/21, 9/16/21, 9/20/21, 9/24/21, 9/27/21, 9/28/21, 9/29/21, 10/3/21, 10/6/21, 10/7/21, 10/10/21, 10/11/21, 10/12/21, 10/13/21, 10/14/21, 10/17/21, 10/20/21, 10/21/21, 10/23/21, 10/26/21, 10/27/21, 10/31/21, 11/3/21, and 11/4/21. The DON stated licensed nurses should follow the physician's order. 5. Review of Resident 8's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 8's physician order indicated she had an order for Norvasc (used to treat high blood pressure) 5 mg one tablet in the morning every Monday, Wednesday, Friday, and Sunday for hypertension (high blood pressure) if her systolic blood pressure (SBP, the pressure in the arteries when the heart beats) was greater than 140, started on 2/26/2020. Review of Resident 8's MARs, from 9/2021 to 11/2021, indicated licensed nurses administered Norvasc 5 mg to Resident 8 when her SBP was below 140 on 9/3/21, 9/8/21, 9/10/21, 9/13/21, 9/15/21, 10/4/21, 10/11/21, 10/17/21, 10/27/21, and 11/5/21. During an interview with the DON on 11/5/21 at 4:10 p.m., she reviewed Resident 8's 9/2021 to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555790 If continuation sheet Page 4 of 18 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 555790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Crest Nursing and Rehabilitation Center 797 E Fremont Avenue Sunnyvale, CA 94087 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 Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 11/2021 MARs and confirmed that licensed nurses administered Norvasc 5 mg to Resident 8 when her SBP was below 140 on 9/3/21, 9/8/21, 9/10/21, 9/13/21, 9/15/21, 10/4/21, 10/11/21, 10/17/21, 10/27/21, and 11/5/21. The DON stated licensed nurses should follow the physician's order. Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated registered nurses should ensure the safety, protection of residents; administration of medications, and therapeutic agents, necessary to implement a treatment, disease prevention, ordered by and within the scope of the licensure of a physician. Event ID: Facility ID: 555790 If continuation sheet Page 5 of 18 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 555790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Crest Nursing and Rehabilitation Center 797 E Fremont Avenue Sunnyvale, CA 94087 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 32's admission Record indicated she was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 32's clinical record indicated she had physician orders for ferrous sulfate 325 milligrams (mg, a metric unit of mass) two times daily at 9 a.m. and 5 p.m. started on 12/31/2020; and for calcium carbonate 500 mg daily at 9 a.m. started on 3/11/21. Thus since 3/11/21 ferrous sulfate and calcium were given to Resident 32 at the same time at 9 a.m. During an interview with the director of nursing (DON) and the consultant pharmacist (CP) on 11/5/21 at 4:21 p.m., the DON reviewed Resident 32's clinical record and confirmed, since 3/11/21, ferrous sulfate and calcium were given to Resident 32 at the same time at 9 a.m. The CP stated ferrous sulfate and calcium should be administered at least two to four hours apart. According to Lexi-comp (www.[NAME].com), a nationally recognized drug information resource, the concurrent use of calcium and ferrous sulfate led to a drug-drug interaction (DDI) of Risk Rating D, which was a significant interaction and required therapy modification. The effect of the DDI was that the calcium may decrease the absorption of oral preparations of iron salts. It indicated the iron absorption was decreased an average of 60% when given as ferrous sulfate and co-administered with calcium. Lexi-comp also indicated to separate the administrations of these medications so it may minimize the potential for significant interaction. Based on interview and record review, the facility failed to ensure an account of all controlled drugs was maintained and reconciled for 3 out of 4 randomly selected residents (Residents 66, 329 and 330) and, to ensure safe and effective use of medications for one of 18 sampled residents (Resident 32) when: 1. Three out of four randomly selected residents' (Residents 66, 329, and 330) controlled medication (those with high potential for abuse and addiction) records did not reconcile. The nursing staff signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but did not document on the Medication Administration Record (MAR) to indicate the controlled medications were given to the residents. This failure had the potential for misuse or diversion of controlled medications; and 2. Resident 32 received ferrous sulfate (iron, for prevention/treatment of iron deficiency anemia) and calcium (a medication used to prevent or treat low blood calcium level) at the same time every day, when the co-administration could lead to decreased absorption of iron. This failure had the potential for the resident not receiving iron supplement as intended. Findings: 1.a. A review of Resident 66's physician's order, dated 10/7/2021, indicated for oxycodone-acetaminophen (brand name: Percocet, a potent controlled medication for pain) tablet 10-325 milligrams (mg, unit of measurement), give 2 tablets by mouth every 4 hours as needed for severe pain related to hip surgery. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555790 If continuation sheet Page 6 of 18 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 555790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Crest Nursing and Rehabilitation Center 797 E Fremont Avenue Sunnyvale, CA 94087 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 On 11/2/21, a review of the CDR for Resident 66's Percocet and October 2021 MAR indicated on 10/30/21, at 1:00 a.m., two tablets of Percocet 10/325 mg were signed out by a nursing staff, but it was not documented on the MAR as given to the resident. During an interview on 11/2/21 at 1:48 p.m. with the director of nursing (DON), she stated nursing staff should sign out controlled drugs on CDR whenever they were taking them out from the narcotic box, administer the medication to the resident, and document on the MAR once the resident had taken the medication. During a concurrent interview and record review on 11/02/21 at 2:12 p.m., with the assistant director of nursing (ADON), inside the DON office, the ADON reviewed Resident 66's medical record and confirmed 2 tablets of Percocet for Resident 66 were not documented on the MAR around the time they were signed out on 10/30/21 at 1:00 a.m. nor was it written in the nursing progress notes. 1.b. A review of Resident 329's physician order, dated 10/25/21, indicated for Norco (a potent controlled medication for pain) tablet 5-325 mg, give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. On 11/2/21, a review of the CDR for Resident 329's Norco and October 2021 MAR indicated on 10/25/21 at 2:30 p.m., one tablet of Norco 5-325 mg was signed out of the CDR by a nursing staff (licensed vocational nurse E, LVN E), but it was not documented on the MAR. During a concurrent interview and record review on 11/02/21 at 1:58 p.m. with ADON, inside the DON's office, he confirmed one Norco 5-325 mg tablet for Resident 329 was not documented on the MAR, nor was it documented in the nursing progress notes, around the time it was signed out of the CDR on 10/25/21 at 2:30 p.m. During an interview on 11/02/21 at 2:07 p.m. with LVN E, she confirmed she could not find her documentation on the MAR, and stated she probably forgot to document. 1.c. A review of Resident 330's physician order, dated 10/14/21, indicated for tramadol (a potent controlled medication for pain) tablet 50 mg, give 50 mg by mouth every 6 hours as needed for severe pain. On 11/2/21, a review of the CDR for Resident 330's tramadol and October 2021 MAR indicated on 10/27/21 at 9 p.m. and 10/28/21 at 9 p.m., one tablet of tramadol 50 mg each night was signed out by a nursing staff, but they were not documented on the MAR. This resulted in two Tramadol 50 mg tablets unaccounted for. During a concurrent interview and record review on 11/2/21 at 2:03 p.m. with ADON, inside the DON's office, he confirmed the tramadol 50 mg were signed out in CDR but not documented as given on the MAR and/or progress notes on both dates and times, 10/27 and 10/28/21 at 9:00 p.m. During a concurrent interview and record review, on 11/2/21 at 4:13 p.m., the DON and ADON provided copies of October MARs for Residents 66, 329 and 330. The MARs indicated all missing nurse's signatures for the above medication administrations were already present on the MAR. Both DON and ADON confirmed they called the nurses who signed out the controlled medications on the CDR to go to the facility earlier that afternoon to sign the MAR. They said the nurses remembered giving them to the residents in October. DON stated a late entry in the MAR was acceptable according to the facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555790 If continuation sheet Page 7 of 18 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 555790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Crest Nursing and Rehabilitation Center 797 E Fremont Avenue Sunnyvale, CA 94087 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 Regulatory and Operations Advisor (RO-ADV). Level of Harm - Minimal harm or potential for actual harm During a telephone interview on 11/8/21 at 10:05 a.m. with the consultant pharmacist (CP), she stated nursing staff should document the administration of controlled medications on the MAR right away to account for the medication administration. Residents Affected - Few Review of the facility's undated policy and procedure titled, Administering Medications, indicated, The individual administering the medication must initial the resident's MAR/EMAR [electronic MAR] on the appropriate line and date for that specific day before administering the next resident's medication. These policy and procedure also reflected, When medications are administered, the individual administering the medication must record in the resident's medical record: The date and time the medication was administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555790 If continuation sheet Page 8 of 18 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 555790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Crest Nursing and Rehabilitation Center 797 E Fremont Avenue Sunnyvale, CA 94087 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of 18 sampled residents (Residents 17 and 43) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors, example is antipsychotics) when: 1. Resident 17 received quetiapine (brand name: Seroquel, antipsychotic medication) 50 milligrams (mg, unit of measurement) since 5/7/2019 without a gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued); and there was no documented clinical rationale by the physician for why an attempted GDR was not indicated. The failure had the potential to result in complications from long term use of Seroquel such as movement disorders, falls with injury, cerebrovascular adverse events [cerebrovascular accidents (CVA), commonly referred to as stroke, and transient ischemic events], and increased risk of death. 2. Resident 43 received Lexapro (medication for depression and anxiety) and lorazepam (an anti-anxiety medication) without GDRs. The failure had the potential for medication interactions, adverse reactions, and increased risks associated with the use of psychotropic medications that included, but not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, and memory loss. Findings: 1. On 11/4/21, a review of Resident 17's clinical record indicated Resident 17 was admitted to the facility with diagnoses of secondary Parkinsonism (a neurologic disease that significantly affects mobility), psychotic disorder with hallucinations due to known physiological condition, delusional disorders, adjustment disorder with mixed anxiety (a mental illness that causes constant fear), depressed mood (a mood disorder that causes a persistent feeling of sadness and loss of interest), unspecified dementia (a condition characterized by memory loss) without behavioral disturbance, and generalized idiopathic epilepsy (a neurological disorder marked by episodes of loss of consciousness or convulsions). A review of Resident 17's clinical record reflected a physician's order, dated 6/1/20, for quetiapine (Seroquel) 50 mg 1 tablet by mouth at bedtime for mania, psychosis, paranoid delusion, hallucination manifested by verbalizing someone trying to arrest him. A review of the medication administration record (MAR), where nursing staff documented the behavior monitoring, indicated Resident 17 only had one episode of hallucination on 10/9/21 on night shift. A review of Interdisciplinary team (IDT, team composed of members from different departments involved in resident's care) psychotropic minutes, dated 7/8/21, for Resident 17 indicated there were 0 incidents [of mania, psychosis, paranoid delusions, hallucinations manifested by verbalizing someone is trying to arrest him] on April, May and June, with IDT recommendation indicating, Pt [patient] is stable, consider GDR to 25 mg. Another review of IDT psychotropic minutes, dated 10/7/21, reflected that there were 0 incidents on July, August and September, with IDT recommendation indicating, Continue for now tried to ask MD [medical doctor] for GDR - but will continue for now. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555790 If continuation sheet Page 9 of 18 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 555790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Crest Nursing and Rehabilitation Center 797 E Fremont Avenue Sunnyvale, CA 94087 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 0758 Level of Harm - Minimal harm or potential for actual harm A review of the consultant pharmacist's (CP) Medication Regimen Review (MRR), dated 7/8/21, indicated the CP recommended a dose reduction of Resident 17's quetiapine from 50 mg to 25 mg. As a response, Resident 17's MD declined a dose reduction of quetiapine, and checked the pre-printed choices of: Resident with good response, maintain the current dose and See physician Progress notes for clinical rationale on 7/16/21. Residents Affected - Few A review of Resident 17's clinical record indicated there were no MD's progress notes, since 7/16/21, documenting the clinical rationale justifying why a GDR should not be attempted. During an interview on 11/5/21, at 11:16 a.m., with Resident 17's MD, he stated his clinical rationale was documented in the progress notes, dated 8/10/21. A review of this progress note indicated MD documented the diagnosis for Seroquel; and under Assessment and Plan, MD documented, Appears controlled. Continue Seroquel 50 mg at bedtime. The MD acknowledged he documented the decision to continue but did not document the clinical rationale or provide justification, such as risk vs benefit assessment, for the continued use and for not attempting a GDR for Resident 17's Seroquel. During a telephone interview on 11/8/21 at 10:05 a.m. with CP, she stated there had been no GDR for Resident 17's Seroquel since May 2019, and confirmed there should be a clinical rationale for the continuation of the medication in the medical record and whenever the physician declined a GDR. During a review of the facility's undated policy and procedure titled, General Guidelines for the Use of Chemical Restraints indicated under Drug Reduction, Residents who use antipsychotic drugs must receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs; Should the gradual dose reduction cause an adverse effect on the resident and the gradual dose reduction is discontinued, documentation of this decision and the reasons for it must be included in the clinical record. A review of Lexi-comp, nationally recognized drug information, indicated adverse effects of quetiapine included: abnormal muscle movements, falls, cerebrovascular events, and increased risk of death. 2.a. Review of Resident 43's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anxiety (people with anxiety frequently have intense, excessive and persistent worry and fear about everyday situations), and depression (a persistent feeling of sadness and loss of interest). Review of Resident 43's physician order indicated she had an order for Lexapro (used to treat depression and anxiety) 5 milligrams (mg, a metric unit of mass) one time a day for depression, started on 9/16/2020. Review of Resident 43's Note To Attending Physician/Prescriber, dated 3/4/21, indicated the pharmacist recommended to reduce Lexapro from 5 mg to 2.5 mg one time a day. The physician agreed with the pharmacist's recommendation and signed it on 3/15/21. However, the physician's order to reduce Lexapro to 2.5 mg was not carried out, and Resident 43 had been still on Lexapro 5 mg since 9/16/2020. During an interview with the director of nursing (DON) on 11/8/21 at 4:45 p.m., she stated the physician's order to reduce Lexapro to 2.5 mg was not carried out because Resident 43's son refused the reduction. However, the DON was unable to provide the document on the refusal of Resident 43's son to reduce Lexapro to 2.5 mg. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555790 If continuation sheet Page 10 of 18 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 555790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Crest Nursing and Rehabilitation Center 797 E Fremont Avenue Sunnyvale, CA 94087 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 0758 Level of Harm - Minimal harm or potential for actual harm 2.b. Review of Resident 43's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anxiety (people with anxiety frequently have intense, excessive and persistent worry and fear about everyday situations), and depression (a persistent feeling of sadness and loss of interest). Residents Affected - Few Review of Resident 43's physician order indicated she had an order for lorazepam (used to treat anxiety disorders) 0.5 milligrams (mg, a metric unit of mass) two times a day for anxiety, started on 7/14/2020. Review of Resident 43's clinical record indicated there had been no gradual dose reduction (GDR) attempt for her lorazepam 0.5 mg two times a day since 7/14/2020. During an interview with the director of nursing (DON) on 11/8/21 at 4:45 p.m., she stated there was no GDR attempt for Resident 43's lorazepam because her son refused the reduction. The DON provided interdisciplinary team (IDT, team composed of members from different departments involved in resident's care) document, dated 4/8/21, with the notes that Resident 43's son refused to change the lorazepam order. However, the physician was not participating in the IDT meeting, and the physician did not sign that he agreed with the IDT recommendations. Review of the facility's undated policy, Tapering Medications and Gradual Drug Dose Reduction, indicated During the first year in which a resident is admitted on a psychopharmacological medication (other than an antipsychotic or a sedative/hypnotic), or after the facility has initiated such medication, the facility will attempt to taper the medication during at least two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, tapering will be attempted at least annually, unless clinically contraindicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555790 If continuation sheet Page 11 of 18 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 555790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Crest Nursing and Rehabilitation Center 797 E Fremont Avenue Sunnyvale, CA 94087 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility had 7.69 percent medication error rate when two medication errors out of 26 opportunities were identified during the medication pass for one of five residents (Resident 42). These failures had the potential to result in an ineffective drug therapy and possible adverse events (such as side effects) for the resident. Residents Affected - Few Findings: 1. During a medication administration observation on 11/01/21 at 9:06 a.m., licensed vocational nurse A (LVN A) crushed one tablet of ferrous sulfate (iron pill, to treat or prevent iron deficiency anemia) 325 milligrams (mg, unit of measurement). She mixed it with about 10 milliliters (ml, volume of measurement) of water and administered to Resident 42 through the gastrostomy tube (G-tube or GT, feeding tube placed through the abdomen into the stomach). During an interview with LVN A on 11/01/21 at 9:58 a.m., LVN A stated the facility had been using the same ferrous sulfate brand from Manufacturer A (MNFTR A), and the nurses had been crushing it to give via G-tube for Resident 42 since 2/20/2021. During another interview with LVN A on 11/01/21 at 4:00 p.m., LVN A stated she verified with their pharmacist the ferrous sulfate tablet should not be crushed, and she will ask the physician to get an order for a liquid form of the medication. Review of LVN A's progress note dated 11/1/21 at 04:01 p.m., indicated, Spoke to [Pharmacy's Name] Pharmacist [name] regarding ferrous sulfate tablet if it can be crushed. [Pharmacist's name] verbalized that it can't be crushed and there's a liquid form of the medication Ferrous elixir 220mg/5 ml. Pharmacist recommend Ferrous elixir liquid 220mg/5 ml 7.4 ml dose for GT. MD [Medical Doctor] notified for clarification order and ok to changed order. During a telephone interview with the Customer Manager from MNFTR A of ferrous sulfate on 11/08/21 at 09:15 a.m., she stated per manufacturer's specifications, their ferrous sulfate tablet product should not be crushed for consumption. During a telephone interview with the facility's consultant pharmacist on 11/08/21 at 10:05 a.m., she agreed ferrous sulfate tablets should not be crushed. 2. During a medication administration observation on 11/01/21 at 09:48 a.m., LVN A was observed preparing 12 medications for Resident 42. LVN A crushed each solid medication individually, placed each in a small medication cup, and added a small amount of water to each cup to dissolve the medications. During the administration at the resident's bedside, LVN A was observed pouring each medication cup, one after another, into the irrigation syringe which was attached to the resident's G-tube. For those that had some medication residuals left in the cup (after pouring), she rinsed the cups with some water and added to the syringe. For those without residuals, she just added one after another into the syringe. At one time, LVN A poured four different medications into the syringe, one after another, without flushing of water in between each medication During an interview with LVN A on 11/01/21 at 09:58 a.m., she verified she did not flush the medications with water in between administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555790 If continuation sheet Page 12 of 18 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 555790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Crest Nursing and Rehabilitation Center 797 E Fremont Avenue Sunnyvale, CA 94087 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the director of nursing (DON) on 11/2/21 at 10:31 a.m., she stated the facility staff followed the physician's order regarding water flush during medication administration through the G-tube. She added the nursing staff should flush the G-tube with water before, between medications, and after medication administration. Review of Resident 42's physician order dated 2/9/2021, indicated, Flush tubing with 10 mls of water before and after medication administration and 10 mls between each individual medication. Review of facility's Policy and Procedure titled, Administering Medications Through an Enteral Tube, dated 07/01/2020, indicated, If administering more than one medication, flush with 15 ml (or prescribed amount) warm sterile or purified water between medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555790 If continuation sheet Page 13 of 18 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 555790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Crest Nursing and Rehabilitation Center 797 E Fremont Avenue Sunnyvale, CA 94087 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. Based on observation, interview, and record review, the facility failed to properly label and store medications and biologicals when: 1. A bottle of lorazepam (anti-anxiety medication) oral liquid solution for Resident 42 was opened but not dated. 2. A vial of Tuberculin Purified Protein Derivative (to test for tuberculosis [TB]) was opened but not dated. 3. Two Systane eyedrops (Artificial Tears) were opened but not dated in medication cart #4. 4. A vial of Heparin (blood thinner to treat or prevent blood clots) injection solution was opened but not dated in medication cart #2. 5. Breo inhaler (medication for breathing problems) was open but not dated in medication cart #2. The deficient practice had the potential for the products to be used beyond the date they were safe and effective for use. Findings: 1. During a concurrent observation and interview with the assistant director of nursing (ADON), on 11/01/21 at 11:01 a.m., in Medication Room Two, an inspection of the medication refrigerator identified a bottle of lorazepam oral liquid solution for Resident 42, which was opened but not dated. The ADON confirmed the lorazepam did not have an open date. A review of the manufacturer's label on lorazepam liquid solution box indicated, Discard opened bottle after 90 days. The ADON verified this information and said it should have been dated when it was opened. 2. During the same observation and interview with ADON as above, on 11/01/21 at 11:01 a.m., in Medication Room Two, an opened vial of Tuberculin Purified Protein Derivative was identified in the medication refrigerator without an open date. During an interview with the ADON on 11/01/21 at 11:05 a.m., he confirmed that the vial of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555790 If continuation sheet Page 14 of 18 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 555790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Crest Nursing and Rehabilitation Center 797 E Fremont Avenue Sunnyvale, CA 94087 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 tuberculin was not dated. Level of Harm - Minimal harm or potential for actual harm 3. During an observation on 11/01/21 at 3:41 p.m., in Station 2, an inspection of medication cart #4 with licensed vocational nurse C (LVN C) identified two bottles of Systane eyedrops which were opened but not dated. Residents Affected - Few During an interview with LVN C, on 11/01/21 at 3:42 p.m., she confirmed the eyedrops should be labeled and dated when opened. Review of the policy and procedure titled, Medications and Medication Labels, dated 05/2016, Section 3.7 indicated, The provider pharmacy permanently affixes label to the outside of prescription containers. Medication labels are not inserted into vials, bags or other containers. For medications designed for multiple administration, (for example, inhalers or eye drops), a label is affixed to product to assure proper resident identification. 4. During an inspection of medication cart #2 with LVN D on 11/02/21 at 10:46 a.m., in Station 1, a vial of Heparin injection solution was identified opened but not dated. LVN D confirmed the Heparin vial was not dated. She stated it should have been dated and should be good for 28 days after opening. 5. During the same inspection of medication cart #2 with LVN D above, a Breo inhaler was found opened but not dated. LVN D confirmed the inhaler was not dated. A review of the manufacturer's label on the Breo carton box indicated, Discard the inhaler 6 weeks after opening the moisture-protective foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first. LVN D confirmed this information. During an interview with the director of nursing (DON) on 11/02/21 at 10:31 a.m., she stated all multi-dose vials, eyedrops, and inhalers should be dated when opened, and nursing staff should just throw them away if not dated. Review of the policy and procedure titled Medications and Medication Labels, dated 05/2016, Section 3.7 indicated, Multi-dose vials shall be labeled to assure product integrity, considering the manufacturers' specifications. (Example: Modified expiration dates upon opening the multi-dose vial.) Nursing staff should document the date opened on multi-dose vials on the attached auxiliary label. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555790 If continuation sheet Page 15 of 18 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 555790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Crest Nursing and Rehabilitation Center 797 E Fremont Avenue Sunnyvale, CA 94087 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a medication administration observation on 11/01/21 at 9:33 a.m., LVN A entered Resident 42's room wearing gloves, carrying all the prepared medications for Resident 42. LVN A adjusted Resident 42's bed height level, touching the bed remote control. She then moved the overbed table, touched Resident 42's bed rail and turned off the feeding pump. LVN A started to check the placement of the resident's gastrostomy tube (or G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) and started with medication administration without changing her gloves and without performing hand hygiene. Residents Affected - Some During an observation on 11/01/21 at 9:48 a.m., LVN A stopped administering medication through the G-tube because she ran out of water for flushing. LVN A went to the faucet inside Resident 42's room, touched the faucet to get some water wearing the same gloves then returned to Resident 42 to resume medication administration. During an interview on 11/01/21 at 9:58 a.m. with LVN A, she stated she only used one pair of gloves for the entire medication administration of Resident 42. LVN A confirmed she did not perform hand hygiene and did not change her gloves when she touched the bed remote control, the overbed table, the bed rail, the feeding pump, and the faucet. LVN A acknowledged she should have performed hand hygiene and changed gloves after touching those objects. A review of the facility's undated policy and procedures, titled, Administering Medications indicated, Established facility infection control procedures must be followed during the administration of medication (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.). A review of the facility's undated policy and procedures, titled, Handwashing/Hand Hygiene indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. It also reflected Handwashing/Hand Hygiene should be done, Before and after direct contact with residents; After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and After removing gloves. Based on observation, interview, and record review, the facility failed to follow proper infection control procedures when: 1. The nebulizer face mask and tubing for two Residents (24 and 28) were found undated and uncovered. 2. Licensed vocational nurse A (LVN A) did not perform hand hygiene and did not change gloves after touching potentially contaminated surfaces during the medication administration for Resident 42. 3. The two staff did not perform hand hygiene during dining observation. These failures put residents, staff and visitors at risk of possible spread of infection. Findings: 3. During an observation on 11/2/21 at 11:54 a.m., during dining observation, restorative nursing aide (RNA) wheeled Resident 44 out of the dining area to endorse to the resident's mother who was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555790 If continuation sheet Page 16 of 18 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 555790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Crest Nursing and Rehabilitation Center 797 E Fremont Avenue Sunnyvale, CA 94087 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 waiting after Resident 44 was done with lunch. The RNA did not sanitize their hands before touching Resident 68's lunch tray and removed it from the food cart and placed it on her table. During the concurrent interview, the RNA validated the observation and she stated, I missed to sanitize my hands. Residents Affected - Some During an observation on 11/2/21 at 12:19 p.m., the student trainee (ST) adjusted Resident 45's facemask to cover his nose snugly. She stated to him let me help you adjust your mask. The ST did not perform hand hygiene or sanitize her hands before she removed Resident 68's mask and got her ready to eat. The ST told Resident 68, let me remove your mask, then assisted Resident 68 to eat. During the concurrent interview, the ST validated the observation and stated that we, should wash hands to prevent contamination and spread of infection. A review of the facility's undated policy and procedures, titled, Handwashing/Hand Hygiene indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. It also reflected Handwashing/Hand Hygiene should be done, Before and after direct contact with residents; After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and After removing gloves. 1. Review of Resident 24's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a disease that causes airflow blockage and breathing-related problems) and asthma (a long-term disease of the lungs, causing the airways to inflame and narrow, making it hard to breathe). Review of Resident 24's physician order indicated he had an order for ipratropium-albuterol solution (used to help control the symptoms of lung diseases) 0.5-2.5 milligrams (mg, a metric unit of mass)/3 milliliters (ml, a metric unit of volume) inhale orally via nebulizer (a machine that turns liquid medicine into a fine mist inhaled into the lungs, mist comes through a tube that is attached to a facemask) four times a day for COPD, started on 10/20/21. During an observation and interview with licensed vocational nurse A (LVN A) on 11/1/21 at 10:55 a.m., Resident 24's nebulizer facemask was not dated and not covered. LVN A stated the facemask should be dated and covered. 1a. Review of Resident 28's admission Record indicated she was admitted to the facility on [DATE] with hypoxemia (low blood oxygen) diagnosis. Review of Resident 28's physician order indicated she had an order for ipratropium-albuterol solution 0.5-2.5 mg/3 ml inhale orally every six hours as needed for wheezing/short of breath/congestion, started on 9/7/21. During an observation and interview with LVN B on 11/1/21 at 2:21 p.m., Resident 28's nebulizer facemask and tubing were not dated, not covered, and were laying on top of the nebulizer machine. LVN B stated the nebulizer facemask and tubing should be dated and covered. Review of the facility's undated policy, Departmental (Respiratory Therapy/Nebulizer) - Prevention of Infection, indicated Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: . Store the circuit in plastic bag, marked with date and resident's name, between uses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555790 If continuation sheet Page 17 of 18 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 555790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Crest Nursing and Rehabilitation Center 797 E Fremont Avenue Sunnyvale, CA 94087 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 Discard the administration set-up every seven days. 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: 555790 If continuation sheet Page 18 of 18