Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cupertino Healthcare & Wellness Center during CMS and state inspections, most recent first.
A resident with multiple arthritis-related diagnoses and chronic pain had an active order for diclofenac sodium to be taken orally twice daily, but two scheduled doses were not administered because the medication was unavailable. The MAR reflected missed doses with a code directing to progress notes, which documented that the drug was not on hand during two consecutive medication passes. The resident reported missing two doses and stated he needed the medication for rheumatoid arthritis. An LVN and the DON confirmed the missed doses due to lack of medication availability, noting that the drug had been ordered from the pharmacy but not delivered in time, contrary to the facility’s policy requiring medications to be administered as prescribed.
A resident with severe cognitive impairment, muscle weakness, bipolar disorder, and a history of right rib fracture was being assisted with a brief change by a CNA who was not assigned to the resident. During care, the CNA held the resident’s wrist in a way reported as uncomfortable, leading the resident to become agitated and strike the CNA’s face. The CNA then slapped the resident on the right side of the face, an act witnessed by another CNA and later documented as a “medium slap” in clinical notes. The resident subsequently sat up and pointed to the affected wrist. The CNA involved had passed background screening and received abuse training at hire, and the facility’s abuse policy defined physical abuse as including hitting and slapping and required staff screening and training on abuse prevention.
Kitchen sanitation and hand hygiene lapses were observed when uncovered cut peaches were placed beside a chemical bucket at the sink area, two dietary staff failed to wash hands before donning gloves during food prep, and an open box of almond nondairy beverage remained in a residents' refrigerator past its use-by date. The DM verified the observations and stated the expired item should not have remained in the refrigerator.
Improper Storage of Refuse in Waste Area: Surveyors observed an overflowing dumpster and additional black plastic bags and cardboard placed outside the dumpster in the designated waste area. The DM and MD confirmed the items should have been inside the bins, and the MD stated refuse should be placed inside the dumpster to prevent attracting pests and for infection control.
Incomplete POLST Lacked Required Signatures: A resident with severe cognitive impairment had a POLST that was mostly blank and did not include the required signatures from the physician and the resident representative/decisionmaker. The DON confirmed the form was not fully completed, and the facility policy stated the POLST must be signed and dated by the practitioner and signed by the resident or representative to be valid.
Incomplete Baseline Care Plan After Admission: A resident admitted with bradycardia, AFib, thrombocytopenia, and HTN had an incomplete baseline care plan, with health condition and medications not completed. The DON confirmed the care plan was incomplete and stated it should be completed within 48 hours of admission to monitor what the resident is taking; the resident also had an order for apixaban 5 mg BID for AFib.
A facility failed to develop individualized care plans for two residents who had one-on-one sitters. One resident had dementia, agitation, failure to thrive, and a history of falls, with severe cognitive impairment and a CNA at bedside because of fall risk; staff confirmed there was no specific sitter care plan. The other resident had severe cognitive impairment, wandering behavior, and an elopement risk evaluation, and although a wander guard was care planned, staff confirmed there was no care plan for the sitter providing constant observation.
Enteral feeding was not provided with appropriate care for a resident with a gastrostomy tube when a feeding bottle was found connected to a running pump for more than 24 hours. The resident had an order for 55 ml/hr via pump for 20 hours per day, and staff interviews confirmed the bottle and tubing should be changed or used only for 24 hours. The facility policy also required enteral tube placement and patency checks before feedings and at each shift.
Daily nurse staffing information was not posted in a clear, readable, or prominent location in the lobby or at nurse stations AA and BB. Observations found no visible staffing posting for residents or visitors, RN C confirmed the posting was unavailable, and the DSD and DON acknowledged the information was in small print and placed behind the check-in kiosk rather than in an easily seen location.
Controlled drug accounting was not maintained accurately when Clonazepam for a resident was dispensed but not recorded in the narcotics log. RN B verified a mismatch between the narcotics count and the blister pack, and the DON confirmed the medication had been given but should have been documented in the narcotics record. The facility policy required controlled substance discrepancies to be reported to the DON immediately and each narcotic dose to be signed out with the date, time, dose, amount remaining, and nurse signature.
A resident receiving Lurasidone for bipolar disorder had no AIMS completed since admission, even after the dose was increased from 20 mg to 40 mg. The DON and CP both verified the missing AIMS during chart review, and the CP stated a baseline AIMS should have been done and included in the med regimen review. During observation, tremors were noted in both hands, and the facility policy required AIMS monitoring on admission, every 6 months, and with dose increases for antipsychotic medications.
Improper Medication Labeling and Storage: Surveyors found multiple opened medications on medication carts without required open or discard dates, including eye drops, Phenytoin oral suspension, and prefilled insulin pens. An opened inhalation powder was also found with an expired date, and staff confirmed several items should have been labeled or discarded per package instructions.
Food was not palatable for residents receiving meals from the kitchen. A cognitively intact resident on a NAS regular diet said the chicken tasted like rubber, and surveyors tasting the lunch meal found the chicken tough and dry. In a separate tray test, surveyors found the pureed chicken parmesan had a strong burned taste, and the DM and RDM confirmed the pureed chicken was not palatable and had an aftertaste.
Infection control practices were not followed during housekeeping and wound care. A housekeeper entered a room with one resident on contact precautions for C. diff and another on EBP wearing only a facemask, without gown or gloves, and did not perform hand hygiene after leaving the room. During wound treatment, an LPN donned new gloves without hand hygiene after handling a box of gloves from the floor, and another LPN contaminated gloves and supplies while treating a resident with a stage 4 sacral PI and other wounds, failed to change gloves, and did not cleanse the sacral wound’s surrounding skin or all ordered thigh wounds before applying dressings and ointment.
A resident with multiple cardiac conditions, who was cognitively intact and able to swallow pills, was given all morning medications crushed and mixed with oatmeal by an LVN without a physician's order. The medications, including several that should not be crushed, were then administered by a CNA, which is outside the CNA's scope of practice. Facility policy and staff interviews confirmed these actions were not in accordance with professional standards.
A resident with complex urinary and renal diagnoses did not receive a physician-ordered urology consultation during their admission, despite multiple documented referrals and ongoing use of an indwelling catheter. Facility staff confirmed the referral was not completed before the resident's discharge, in violation of facility policy and physician orders.
A resident was left with oral medication unsupervised at bedside, contrary to professional standards. The LVN confirmed leaving the medication and acknowledged the error. The DON verified that the resident had no order for self-administration. The Medication Administration Record inaccurately documented the administration time. The resident had diagnoses including muscle weakness and paranoid schizophrenia.
The facility failed to provide appropriate social services for two residents after altercations. The Social Services Director did not perform or document required psychosocial assessments for the residents involved, despite acknowledging this responsibility. The Director of Nursing confirmed the necessity of a 72-hour psychosocial status check, which was not completed, potentially affecting the residents' well-being.
A resident, diagnosed with Ankylosing Spondylitis and cognitively intact, requested to change physicians, but the facility failed to assist. The SSA acknowledged the request but did not follow up, assuming the DON would handle it. This inaction violated the facility's policy supporting residents' rights to choose their attending physician.
A resident in an LTC facility did not receive necessary vision services, resulting in impaired vision due to the lack of prescription eyeglasses. Despite being on a referral list and having scheduled appointments, the resident was not seen by an eye doctor, and there was no documentation explaining the missed appointments. The resident's physician orders indicated a need for an eye health and vision consult, which was not fulfilled.
A resident with Alzheimer's and dementia, assessed as at risk for elopement, was able to leave the facility unsupervised due to a failure to implement the care plan intervention of marking the resident's wheelchair with a purple ribbon. The absence of this ribbon allowed the resident to transfer to another wheelchair without a wanderguard, leading to an elopement incident.
A resident, admitted for aftercare following joint replacement surgery, reported that his roommate grabbed his leg, causing distress and inability to sleep. Despite the resident's request to be moved, the facility did not separate the two residents immediately, violating the facility's abuse and neglect policy.
A resident who tested positive for COVID-19 was not isolated as required, leading to potential exposure in the facility. The resident left their room without a mask and entered the rehab gym, contrary to the facility's policy. Staff interviews confirmed the resident's non-compliance and the failure to adhere to infection control protocols.
The facility failed to properly store and label food items, as observed by a surveyor. Bell peppers with mold, undated cheese, and exposed diced ham were found in the kitchen, along with improperly sealed dry goods. Staff interviews confirmed these deficiencies, highlighting a lapse in following the facility's food storage policy.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in their medical records. Two residents with serious mental illnesses were inaccurately assessed as not having such conditions, despite state evaluations recommending specialized services. Another resident's discharge MDS incorrectly indicated a hospital discharge instead of a home discharge. Staff interviews confirmed these inaccuracies.
A resident with cognitive impairment and mental health diagnoses was observed yelling frequently, but the behavior was not included in their care plan. Facility staff, including a CNA, RN, and LVN, expected the behavior to be care planned. The facility's policy requires care plans to be updated based on assessed needs, but the resident's care plan lacked any mention of the yelling behavior, as confirmed by the Administrator and DON.
Two residents in an LTC facility did not receive proper nail care as required by their care plans. One resident, with a history of contractures and hemiparesis, and another with type 2 diabetes, were both observed with long fingernails despite needing assistance with personal hygiene. Staff interviews confirmed that nail trimming should have occurred on bath days, but this was not done, leading to deficiencies in their ADLs.
A resident with a history of dementia and mobility issues experienced an unwitnessed fall resulting in a head injury. The facility failed to determine the root cause of the fall, as the incident report was incomplete and staff provided inconsistent accounts. The DON acknowledged the need for better documentation and investigation.
A resident with severe cognitive impairment and a history of gastrostomy status was administered the wrong enteral feeding formula. The physician's order specified Nepro 1.8, but Jevity 1.2 was given instead. LVNs involved did not verify the formula against the order, and the error was confirmed by the facility's administration.
A resident with Alzheimer's and dysphagia was not served the prescribed pureed diet due to communication failures. Despite a physician's order to change the diet, the resident received a mechanical soft meal. The LVN communicated the change to another LVN, who informed the RD, but the RD was unaware of the change, leading to the incorrect meal being served.
A facility failed to implement enhanced barrier precautions (EBP) during catheter care for a resident with an indwelling catheter and severe cognitive impairment. Despite new CMS guidelines requiring EBP for residents with indwelling devices, staff wore gloves and masks but not gowns. Interviews revealed a lack of awareness and understanding of the new EBP requirements among staff, including the Infection Control LVN. The Director of Nursing and Administrator expected compliance with PPE use but did not ensure it.
A resident received unnecessary doses of milk of magnesia (MOM) due to a transcription error by nursing staff, leading to potential health risks. The resident, who was always incontinent and did not have constipation, was administered MOM daily instead of every third day as needed. This error resulted in an unwitnessed fall and required the interdisciplinary team to monitor for adverse reactions.
Failure to Ensure Availability of Prescribed Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident when prescribed diclofenac sodium was not available for administration for two scheduled doses. The resident had multiple arthritis-related diagnoses, including ankylosing spondylitis of the spine, rheumatoid arthritis, osteoarthritis, other chronic pain, and arthropathy, and was cognitively intact with a BIMS score of 15. The resident had an active order for diclofenac sodium 25 mg, three tablets by mouth twice daily for rheumatoid arthritis. The MAR for the relevant period showed code 9 entries for the scheduled diclofenac doses, indicating "Other/See Progress Notes" for one evening and one morning administration time. Nursing progress notes documented that during medication pass on one evening, the resident’s prescribed diclofenac was unavailable, and that the medication remained unavailable the following morning. In an interview, the resident confirmed missing two doses of diclofenac sodium and stated he badly needed the medication for rheumatoid arthritis, adding that nurses did not give the medication and blamed the pharmacy. An LVN confirmed not administering the morning dose because the medication was not available and stated that nurses should order medications several days before they are consumed and that the pharmacy should deliver within 24 to 48 hours. The DON stated nurses should order medications three days prior to running out and confirmed the resident missed two doses because the medication was not available, further stating that diclofenac had been ordered from the pharmacy on two prior dates and was not delivered on time. The facility’s medication administration policy required medications to be administered as prescribed to ensure compliance with dose guidelines.
Failure to Protect Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by staff. The resident was admitted with diagnoses including muscle weakness, bipolar disorder, and a right rib fracture sequela, and had a BIMS score of 5 indicating severe cognitive impairment. Nursing notes documented a change in condition monitoring for swelling to the left radial wrist and skin discoloration on the left inner thigh, and an x-ray later showed mild degenerative joint disease of the left wrist. During personal care, a CNA who was not assigned to the resident assisted with a brief change. According to the facility-reported incident, the resident became agitated and scratched the CNA’s face, after which the CNA slapped the resident on the right side of the face. An eInteract SBAR summary documented that the assigned CNA witnessed the other CNA slap the resident on the right side of the face with a “medium slap” while attempting to provide care. In an interview, the witnessing CNA stated that the assisting CNA insisted on holding the resident’s wrist despite being told it was uncomfortable for the resident, that the resident freed a hand and hit the CNA’s face, and that the CNA then hit the resident back in the face and left the room. The resident then sat up in bed and pointed to the wrist. The CNA who committed the abuse had been hired several months earlier, had undergone background screening, and had last received abuse training at orientation. The facility’s abuse prevention and management policy defined physical abuse as including hitting and slapping and required screening and training of staff on abuse prevention and understanding resident behaviors that may increase the risk of abuse.
Kitchen sanitation and hand hygiene lapses
Penalty
Summary
Sanitary conditions were not maintained in the kitchen when a clear square food storage container holding peeled, sliced, and chopped peaches was observed uncovered beside the red and green bucket with chemical solution at the three-compartment sink tap. During the observation, the Dietary Manager and Dietary staff verified that the peaches should not have been placed near the bucket because the area was not clean and could cause food contamination. Hand hygiene was not performed by kitchen staff before donning gloves during food service activities. One dietary staff member picked up a kitchen thermometer that had fallen on the floor and then took a new thermometer without washing hands before putting on new gloves, and another dietary aide was observed fixing her hairnet and clothes and then preparing food with gloves on without handwashing. In addition, an open box of almond nondairy beverage was found in the residents' refrigerator with an open date of 12/18/25 and a use-by date of 12/21/25, and it remained there on 12/22/25; the Dietary Manager stated expired food should be thrown out and should not remain in the refrigerator.
Improper Storage of Refuse in Waste Area
Penalty
Summary
Dispose of garbage and refuse properly was cited after surveyors observed that the facility did not ensure refuse materials were stored and disposed of properly. On 12/19/25 at 8:12 a.m., during an initial observation at the designated waste area, one garbage dumpster was observed to be overflowing. On 12/22/25 at 9:00 a.m., during a concurrent observation and interview with the Dietary Manger and Maintenance Director at the designated waste area, two black plastic bags and cardboard were observed outside of the dumpster. Both the Maintenance Director and Dietary Manger confirmed the observation and stated the items should be placed inside the bins. The Maintenance Director stated garbage should be placed inside the dumpster to prevent attracting pests and for infection control. The report also cited the facility's Waste Management policy, revised 4/2022, and the FDA 2022 Food Code requirement that refuse be stored in receptacles so it is inaccessible to insects and rodents.
Incomplete POLST Lacked Required Signatures
Penalty
Summary
The facility failed to have a valid copy of Resident 3's POLST. Resident 3's MDS dated 12/18/25 showed admission on [DATE] and a BIMS score of 00, indicating severe cognitive impairment. The resident's POLST was reviewed and was undated, and it stated that to be valid it must be signed by a physician, nurse practitioner, or physician assistant, and by the patient or decisionmaker. During a concurrent interview and record review on 12/19/25 at 3:08 p.m., the DON reviewed Resident 3's POLST and stated it should be completed by the resident representative and then the physician should be notified and asked to sign. The DON verified that the POLST was mostly blank and did not contain signatures from the physician or the resident representative/decisionmaker. The facility policy titled Physician Orders for Life-Sustaining Treatment, revised June 3, 2020, stated the POLST must be completed, signed, and dated by the practitioner and signed by the resident or resident's representative or health care decision maker.
Incomplete Baseline Care Plan After Admission
Penalty
Summary
The facility failed to ensure that Resident 151 had a baseline care plan completed within 48 hours of admission. Resident 151 was admitted on 9/5/25 with diagnoses including bradycardia, unspecified atrial fibrillation, thrombocytopenia, and hypertension. The resident’s order summary showed an order for Apixaban 5 mg by mouth twice daily for atrial fibrillation. A review of Resident 151’s baseline care plan dated 9/23/25 showed that the health condition and medications were not completed. During interview and record review on 12/19/25, the DON confirmed that the baseline care plan was incomplete. The DON stated the baseline care plan should be completed within 48 hours of admission to monitor what the resident is taking. The facility policy titled Person-Centered Care Planning, revised 4/24/2025, stated that the baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon admission and should address resident-specific health and safety concerns, supervision needs, behavioral interventions, and assistance with ADLs.
Failure to Care Plan One-on-One Sitters for Two Residents
Penalty
Summary
The facility failed to develop individualized, resident-centered care plans for two residents who had sitters. Resident 20 was admitted with diagnoses including dementia with agitation, adult failure to thrive, and a history of falling. Her BIMS score was 0, indicating severe cognitive impairment. During observation, she was seen asleep in bed with a CNA at bedside serving as a sitter because she was at risk for falling; another observation showed a CNA at bedside, and later she was observed walking in the hallway with CNA assistance. The MDS nurse confirmed there was no specific care plan for Resident 20's sitter and stated the sitter should have been care planned when initiated. The DON also confirmed there was no care plan developed and stated the sitter was part of interventions for fall and elopement risk. Resident 3 was admitted with diagnoses including metabolic encephalopathy, senile degeneration of the brain, dementia with agitation, cognitive communication deficit, and major depressive disorder with psychotic symptoms. The resident's MDS showed a BIMS score of 0, indicating severe cognitive impairment. During observation, Resident 3 was asleep in bed with a CNA sitting beside and watching the resident, and the CNA stated he was the sitter because the resident wanders. Another observation showed the CNA still at bedside, and the LVN confirmed Resident 3 had a sitter. The record showed an elopement evaluation with a score of 4.0 and a care plan for a wander guard on the right wrist with interventions to check the guard, monitor wandering every shift, and monitor skin integrity, but the DON confirmed there was no care plan for the one-on-one sitter and stated it should have been individualized for the resident.
Enteral Feeding Ran Beyond 24 Hours
Penalty
Summary
Enteral feeding was not provided with appropriate care and services for one resident with a gastrostomy tube. During an observation, the resident was in bed with eyes closed and had an enteral feeding bottle connected to a running pump, with contents below 300 ml. The bottle showed it had started on 12/15/25 at 1 a.m., and the observation occurred on 12/16/25 at 9:22 a.m., indicating the feeding had been running for more than 24 hours. The resident’s record showed an admission date of 3/22/23 and diagnoses that included gastrostomy status. The physician order for the resident directed enteral feed 55 ml/hr via pump for 20 hours per day, with the pump off at 1000 and on at 1400. During interviews, an LVN stated the enteral feeding bottle and tubing must be changed every 24 hours, another LVN stated the bottle should not run for more than 24 hours, and an RN stated the bottle and tubing should only be good for 24 hours. The facility’s policy stated enteral tubes should be verified for placement and patency prior to intermittent feeding, at every shift, and prior to administering medications, hydration, and nutrition via enteral feeding tubes.
Daily Nurse Staffing Information Not Posted Clearly or Prominently
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted in a clear and readable format and in a prominent place readily accessible to residents, staff, and visitors. During multiple observations from 12/16/2025 to 12/19/2025, between 8:30 a.m. and 10:30 a.m., there was no daily staffing information posted in the lobby, at nurse station AA, or at nurse station BB, and there was no staffing information placed on top of the lobby desk or on top of either nurse station. During an observation on 12/22/2025 at 9:35 a.m., the lobby still did not have daily staffing information that could easily be seen by visitors or residents, and at 9:39 a.m. there was no posting at nurse station AA. During a concurrent observation and interview at nurse station BB, RN C confirmed the daily staffing information posting was not available. The DSD later showed staffing information written in fine print and posted behind the facility's check-in kiosk, and confirmed it could not be seen right away when a visitor entered the lobby. The DON also confirmed the staffing information was printed in small print and stated it used to be located on top of the lobby desk. The facility policy required daily posting of nurse staffing data in a clear and readable format and in a prominent place readily accessible to residents and visitors.
Controlled Drug Count Not Reconciled
Penalty
Summary
The facility failed to maintain an accurate account of controlled drugs and to periodically reconcile them when Clonazepam was dispensed for one resident but was not recorded in the Narcotics Record book. During a concurrent observation and record review of the Station 2 medication cart, RN B verified that the Narcotics Record book showed the resident had 16 remaining Clonazepam pills dated 12/15/25 at 5:20 p.m., while the Clonazepam blister pack for the resident contained 15 pills. The resident’s physician order indicated Clonazepam 1 mg, 1 tablet by mouth twice daily for anxiety manifested by continuous yelling, screaming, and calling out. During interview and record review, the DON verified that Clonazepam was administered to the resident on 12/16/25 at 9:00 a.m. and stated it should have been recorded in the Narcotics Record book if a Clonazepam pill was taken. The DON also stated she was not informed of the incident and that nurses must report any discrepancies in the Narcotics Record book immediately. RN B stated she clarified the discrepancy with the nurse-in-charge immediately and that every controlled drug taken and administered to residents must be recorded in the Narcotics Record book; RN B also stated the issue should have been reported to the DON. The facility’s policy required discrepancies in controlled substance counts to be reported to the DON immediately and required licensed nurses to document the date, time, dose, amount remaining, and signature when signing out a narcotic medication.
Failure to Complete AIMS Monitoring for Resident on Lurasidone
Penalty
Summary
The facility failed to ensure irregularities were identified during the monthly drug regimen review for a resident receiving Lurasidone. Resident 17 was admitted with diagnoses including unspecified dementia, anxiety, and bipolar disorder, and the physician order showed Lurasidone HCl 40 mg by mouth in the evening for bipolar disorder with depressive mood and withdrawal from prior activity. During a concurrent interview and record review with the DON, it was verified that the resident’s Lurasidone dose had been increased in November 2025 and that no AIMS had been completed since admission, although the DON stated it should have been done. During a concurrent interview and record review with the Consultant Pharmacist, it was verified that Lurasidone was started in the facility, the dose was increased from 20 mg to 40 mg in November 2025, and no AIMS had been completed since admission. The CP stated there should have been a baseline AIMS and that the increased dose carried an increased risk for EPS. The CP also stated AIMS should have been included in the medication regimen review recommendation. During observation, the resident was in a wheelchair after lunch, and tremors were noted in both hands. The facility policy required an AIMS upon admission, every six months, and with dose increases for residents prescribed antipsychotic medications.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure proper medication storage and labeling of medications. During observation and interview at Station 5 Medication Cart, an opened Latanoprost eye drop medication had an open date label but no discard date label, another opened Latanoprost eye drop medication had an opened and discard date label of 11/15-[DATE] and was stated by the LVN to have should have been discarded, an opened Bimatoprost eye drop medication had no open or discard date labels, and an opened bottle of Phenytoin Oral Suspension had no open date label. The LVN stated the open date should have been indicated on the bottle. During observation and interview at Station 2 Medication Cart, a prefilled insulin pen had no open and discard date label, and an opened inhalation powder had an opened date of [DATE] and an expiry date of 12/8. During observation and interview at Station 3 Medication Cart, an opened prefilled insulin pen did not indicate an open and discard date. RN C stated the open and discard date should be written on the insulin pen. The facility policy stated medications and biologicals are to be stored safely, securely, and properly, following manufacturer recommendations, and outdated, contaminated, or deteriorated medications are to be immediately removed from stock.
Food Not Palatable
Penalty
Summary
Food served from the facility kitchen was not palatable. Resident 8 was admitted on [DATE], and his MDS dated 10/29/25 showed a BIMS score of 15, indicating he was cognitively intact. His record also showed he was on a NAS regular diet. During an interview on 12/16/2025, Resident 8 stated the facility does not know how to cook chicken and described the chicken texture as similar to rubber. During a lunch meal observation and taste test with three surveyors and two DMs, the facility’s menu listed chicken, pasta marinara sauce, and spinach for the regular diet. All three surveyors agreed the chicken was tough and dry. During a separate test tray observation with the DM and RDM, the regular tray included chicken parmesan, penne with garlic and herbs, and spinach with onions, and the pureed tray included pureed chicken, penne pasta, and spinach. The survey team found the pureed chicken parmesan had a strong burned taste, and the RDM verified the pureed chicken had an aftertaste and stated it would follow up on the concern. The DM and RDM later confirmed the pureed chicken was not palatable, and the RDM confirmed the texture of the pureed chicken was not palatable.
Infection Control Failures During Housekeeping and Wound Care
Penalty
Summary
The facility failed to ensure infection control practices were implemented during care and housekeeping activities. One housekeeper was observed mopping inside the room of two cohorted residents, one on contact precautions for recurrent C. diff and the other on enhanced barrier precautions due to a feeding tube, while wearing only a facemask and no gown or gloves. The housekeeper moved the residents’ overbed tables, touched the privacy curtain and garbage container, and exited the room without performing hand hygiene before continuing to sweep and touch the cleaning cart. During wound care for a resident with a stage 4 sacral pressure injury, chronic venous insufficiency, non-pressure ulcers of the right lower leg, and an above-knee amputation, an LVN removed gloves and picked up a box of gloves that had fallen on the floor, then donned a new pair of gloves without hand hygiene. During the same treatment, another LVN handled contaminated gauze wrappers and the gauze box, continued wound care without changing gloves, and exposed the sacral stage 4 pressure injury while cleaning the right lower leg wounds. The wound treatment also showed that the sacral wound’s surrounding skin was not cleansed before dressing application, and the wounds on the back of the resident’s right thigh were not all cleansed as ordered. The LVN cleansed only one open wound on the right posterior thigh and then applied zinc oxide ointment to all wounds without cleaning them. The DON confirmed that gloves should be changed after touching dirty surfaces, hand hygiene should be performed before donning new gloves, and wounds and surrounding skin should be cleansed before treatment orders are applied.
Improper Medication Administration and Scope of Practice Violation
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) crushed all of a resident's morning medications, mixed them with oatmeal, and left them at the resident's bedside. The resident, who had a history of myocardial infarction, atrial fibrillation, chronic systolic heart failure, and hypertension, was cognitively intact and had no documented swallowing difficulties. According to interviews and record review, the resident typically took medications whole with water and had not requested for them to be crushed. The LVN did not obtain a physician's order before crushing the medications, which included several that should not be crushed, such as enteric-coated aspirin, isosorbide mononitrate extended-release, and pantoprazole delayed-release tablets. A certified nursing assistant (CNA) subsequently administered the oatmeal mixed with crushed medications to the resident, despite this being outside the CNA's scope of practice. The CNA confirmed that she assisted the resident with breakfast and provided the oatmeal with medications after the LVN left the room. The resident noticed the altered taste and reported the issue to a family member, who also confirmed that the CNA had given the medication-laced oatmeal. Facility policy states that only licensed nurses are to administer medications and that a physician's order is required to crush medications. Interviews with staff, including the director of staff development and the director of nursing, confirmed that the CNA should not have administered medications and that the LVN misinterpreted the resident's needs. The facility's own policies and in-service training materials reinforce that medication administration is the responsibility of licensed nurses and that CNAs are not permitted to give medications to residents.
Failure to Provide Timely Urology Consultation as Ordered
Penalty
Summary
A deficiency occurred when a resident with diagnoses including end stage renal disease, obstructive and reflux uropathy, and urinary retention did not receive a urology consultation as ordered by the physician. The resident was admitted with an indwelling urinary catheter, and physician orders and progress notes repeatedly documented the need for a urology referral and evaluation. Despite these orders, the resident was not seen by a urologist during their stay, and the referral remained pending throughout their admission. Interviews with facility staff, including the DON and Nurse Supervisor, confirmed that the urology consult was ordered but not completed, with the Nurse Supervisor stating that referrals typically take a month or more to process. The resident ultimately was discharged against medical advice without having received the required urology evaluation. Facility policy indicated that the Director of Social Services, with assistance from nursing staff, was responsible for arranging such referrals, but this process was not completed in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that treatment and care were provided in accordance with professional standards of practice when a resident was left with oral medication to be taken unsupervised at bedside. During an observation, a medicine cup with two white capsules and a plastic cup of water were found on the resident's bedside table. The resident confirmed that the nurse left the medication for her to take. A Certified Nurse Aide verified the presence of the capsules and called the resident's nurse. The Licensed Vocational Nurse (LVN) confirmed that she left the medications and acknowledged that it was not appropriate to leave medications at the bedside without supervision. The Director of Nursing (DON) confirmed that medications should not be left at the bedside without a doctor's order for self-administration, which the resident did not have. A review of the Medication Administration Record showed that the medication, Gabapentin, was documented as administered at a specific time, but the LVN confirmed she did not administer it at that time. The resident's clinical record indicated diagnoses of muscle weakness, paranoid schizophrenia, and major depressive disorder. The facility's policy required that medications be given by the licensed nurse preparing them and documented accurately, which was not followed in this instance.
Failure to Conduct Psychosocial Assessments After Altercations
Penalty
Summary
The facility failed to provide sufficient and appropriate social services for two residents following resident-to-resident altercations. The Social Services Director (SSD) acknowledged her responsibility to conduct psychosocial and emotional assessments for residents involved in altercations and to document these assessments in the residents' electronic charts. However, the SSD did not perform or document these assessments for Resident 10 and Resident 7 after their respective incidents. Resident 10 was involved in an altercation with another resident, where Resident 10 allegedly tapped the other resident's legs, but no follow-up assessment was documented. Similarly, Resident 7 was allegedly grabbed and kicked by another resident, yet no psychosocial assessment was recorded. The Director of Nursing (DON) confirmed that a 72-hour psychosocial status check should be conducted by social services and documented in the resident's chart. The facility's job description for the Social Services Coordinator outlines the responsibility to assess the psychosocial, mental, and emotional needs of residents and communicate these needs to relevant parties. The lack of documentation and follow-up assessments for the involved residents indicates a failure to adhere to these responsibilities, potentially impacting the residents' psychosocial well-being.
Failure to Honor Resident's Physician Choice
Penalty
Summary
The facility failed to honor a resident's right to choose their attending physician, as evidenced by the actions and inactions of the social services assistant (SSA). The resident, who was cognitively intact and diagnosed with Ankylosing Spondylitis of the Spine, expressed a desire to switch physicians approximately two months prior to the survey. The SSA acknowledged the resident's request and believed she had informed the director of nurses (DON) but did not follow up on the matter. During interviews, the SSA admitted to not knowing the procedure for changing physicians and assumed the DON would handle it. The facility's policy, which supports residents' rights to choose their attending physician, was not adhered to, leading to a potential compromise of resident rights.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to provide necessary vision services for a resident, resulting in impaired vision due to the lack of prescription eyeglasses. The resident, who had clear speech and adequate vision with corrective lenses as per the Minimum Data Set assessment, reported that their glasses were taken and no assistance was provided to make an appointment for new ones. Despite a referral being sent to an eye doctor, the resident was not seen on the scheduled dates, and there was no documentation explaining why the appointments on 4/29/24 and 7/9/24 did not occur. Interviews with the Social Services Associate and Social Services Director revealed that the resident was on the referral list but was not evaluated. The resident continued to express concerns about not having an appointment for their glasses. Although an appointment was eventually scheduled, the resident could not be seen because they were on a gurney. The physician's orders from 11/15/2022 indicated a need for an eye health and vision consult, highlighting the ongoing issue of unmet vision care needs.
Failure to Implement Elopement Care Plan for Resident
Penalty
Summary
The facility failed to implement the elopement care plan for a resident diagnosed with Alzheimer's disease and dementia, who had a history of wandering and falling. The resident was assessed as being at risk for elopement, with a score indicating such risk. Despite this, the resident was able to transfer herself to another wheelchair without a wanderguard and elope from the facility, reaching a nearby street corner. This incident occurred because the care plan intervention, which required a purple ribbon to be tied on the resident's assigned wheelchair to ensure staff could identify it, was not followed. During an observation, it was noted that the purple ribbon was missing from the resident's wheelchair, contrary to the care plan. Interviews with the LVN and DON revealed that the staff were aware of the resident's elopement risk and the care plan intervention involving the purple ribbon. However, the intervention was not consistently implemented, as evidenced by the absence of the ribbon during the observation. The DON confirmed that the care plan required the ribbon to be on the wheelchair and acknowledged that the staff should adhere to the care plan to ensure the resident's safety. The facility's policy on wandering and elopement emphasized the importance of identifying residents at risk and implementing measures to minimize such risks, which was not effectively executed in this case.
Failure to Separate Residents After Incident
Penalty
Summary
The facility failed to ensure a resident was free from abuse when two residents were not separated after an incident. Resident 1, who was admitted for aftercare following joint replacement surgery, reported that his roommate, Resident 2, grabbed his leg on the first night of admission. Despite Resident 1's distress and request to be moved, the facility staff did not separate the two residents immediately, resulting in Resident 1 feeling terrified and unable to sleep. The Director of Nursing acknowledged that the residents should have been separated sooner. The Nursing Supervisor's review of progress notes indicated that Resident 1 was upset and called 911 after his roommate's actions. The facility's policy on abuse and neglect required immediate separation of residents in such situations, but this was not adhered to until later in the morning after an interdisciplinary care team meeting.
Failure to Isolate COVID-19 Positive Resident
Penalty
Summary
The facility failed to implement effective infection prevention and control strategies to prevent the spread of COVID-19 when a resident, who tested positive for COVID-19, was not isolated as required. The resident, identified as Resident 3, was admitted with a positive COVID-19 test and was supposed to be under contact/droplet precautions for 10 days. However, the resident left their room without a mask and entered the rehab gym, which was against the facility's policy that restricted movement of COVID-positive residents to their rooms unless for medically necessary purposes. Interviews with staff and residents revealed that Resident 3 was in the gym for an extended period without a mask, and staff had to intervene to escort the resident back to their room. The Infection Preventionist confirmed that Resident 3 was non-compliant and combative, and despite consulting with the county infection prevention consultant, the resident was not kept in isolation as recommended. The facility's policy clearly stated that residents on transmission-based precautions should remain in their rooms, highlighting a failure in adherence to the established infection control protocols.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to its food storage policy, resulting in several deficiencies related to the handling and storage of food items. During an observation, a surveyor found improperly stored food items in the kitchen, including bell peppers with a black fuzzy substance and fluid seeping from the container, undated bags of cheese, and an undated bag of diced ham exposed to air in the walk-in freezer. Additionally, containers of dry milk, lima beans, and rice were found open to air in the dry storage area. These findings indicate a failure to label, date, and properly seal food items as required by the facility's policy. Interviews with facility staff, including a Dietary Aide, Registered Dietician, Dietary Supervisor, Director of Nursing, and the Administrator, confirmed the deficiencies. The Dietary Aide acknowledged that the bell peppers were spoiled and should have been discarded earlier, and the cheese should have been labeled with an opened and use-by date. The Registered Dietician and Dietary Supervisor emphasized the importance of sealing food items and labeling them correctly. The Director of Nursing and Administrator reiterated the facility's policy requirements for labeling and sealing food items, highlighting a lapse in following established procedures.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their medical records. Resident #50, who was admitted with a history of paranoid schizophrenia, schizoaffective disorder, and major depressive disorder, was inaccurately assessed in the MDS as not having a serious mental illness, despite a prior state evaluation recommending specialized services. Similarly, Resident #65, with diagnoses of major depressive disorder and adjustment disorder, was also inaccurately assessed in the MDS, contradicting a state evaluation that recommended specialized services. Interviews with the MDS Nurse, Administrator, and Director of Nursing confirmed these inaccuracies. Resident #159's discharge MDS was also found to be inaccurate. The resident, who had a history of Parkinson's disease and type two diabetes, was recorded as being discharged to a short-term general hospital, whereas the discharge planning review indicated the resident was discharged to a private home with home health services. The MDS Nurse and Director of Nursing acknowledged the error, emphasizing the importance of correct coding for tracking residents in emergencies. The Administrator also highlighted the significance of accurate discharge MDS coding.
Failure to Address Resident's Yelling Behavior in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the yelling behavior of a resident with a medical history of mild cognitive impairment, schizophrenia, and major depressive disorder. The resident was admitted on December 20, 2023, and a quarterly Minimum Data Set (MDS) assessment on March 28, 2024, indicated severe impairment in cognitive skills for daily decision-making, but did not document any behaviors. Despite this, observations on May 27 and May 29, 2024, noted the resident yelling intermittently and unintelligibly. Interviews with facility staff, including a CNA, RN, and LVN, revealed that the resident's yelling was a known behavior, and staff expected it to be included in the care plan. The facility's policy on Comprehensive Person-Centered Care Planning, revised in November 2028, mandates that care plans be updated based on assessed needs. However, the resident's care plan lacked any mention of the yelling behavior, which was confirmed by the Administrator and the Director of Nursing during an interview on May 31, 2024. They acknowledged that the behavior should have been care planned.
Failure to Provide Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, leading to deficiencies in their activities of daily living (ADLs). Resident #20, who was admitted in 2015 and has a medical history of contractures and hemiparesis following a cerebral infarction, was observed multiple times with long fingernails despite being dependent on staff for personal hygiene. The resident's care plan required staff to check and trim nails on bath days and as needed, but observations and interviews revealed that this was not done. The resident expressed a desire to have their nails trimmed, indicating that the staff did not fulfill this aspect of care. Similarly, Resident #93, admitted in 2023 with a history of type 2 diabetes and requiring substantial assistance for personal hygiene, was also found with long fingernails. The care plan for this resident also required nail trimming on bath days and as necessary. Interviews with staff, including CNAs and LVNs, confirmed that the nails should have been trimmed during the resident's bath/shower days. Despite the facility's policy and staff expectations, the necessary nail care was not provided, as confirmed by the Director of Nursing and the Administrator.
Failure to Determine Root Cause of Resident Fall
Penalty
Summary
The facility failed to determine a root cause for a fall involving a resident, which was a deficiency in their fall management program. The resident, who was admitted with a medical history of adult failure to thrive, dementia, altered mental status, abnormalities of gait and mobility, and weakness, was identified as high risk for falls. Despite this, the facility did not adequately document or investigate the circumstances surrounding the resident's unwitnessed fall, which resulted in a head injury requiring hospital treatment and staples. Interviews with facility staff, including the Director of Nursing (DON), revealed that the fall incident report for the resident contained many blanks and did not provide a complete picture of the event. The Licensed Vocational Nurse (LVN) and Certified Nurse Aide (CNA) involved in the incident provided inconsistent accounts of the fall, and the DON acknowledged the need for improvement in documenting and understanding the root cause of such incidents. The Administrator also expressed an expectation for staff to determine and document the root cause of falls, which was not met in this case.
Incorrect Enteral Feeding Formula Administered
Penalty
Summary
The facility failed to administer the correct enteral gastrostomy tube feeding as ordered for a resident with a medical history of gastrostomy status and adult failure to thrive. The resident, who was severely impaired in cognitive skills for daily decision-making, was admitted with a care plan requiring tube feeding due to swallowing problems. The physician's order specified the administration of Nepro 1.8 at 40 ml/hr for 20 hours daily. However, during an observation, it was found that the resident was receiving Jevity 1.2 instead of the prescribed Nepro 1.8. Licensed Vocational Nurse (LVN) #9 confirmed the error upon reviewing the physician orders, and LVN #10 admitted to starting the incorrect formula without verifying it against the order. The Medical Doctor was informed of the error but expressed no immediate concern. The facility's Administrator and Director of Nursing acknowledged the mistake, emphasizing that the staff should have verified the physician's order and the formula before administration.
Failure to Serve Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to ensure that a therapeutic diet was served to a resident as ordered by the physician. The resident, who was admitted with a medical history of Alzheimer's disease and dysphagia, was initially on a mechanically altered diet. A physician's order on the morning of the incident changed the resident's diet to a regular, pureed texture diet. However, during a meal observation, a Certified Nurse Aide (CNA) was seen setting up a mechanical soft meal tray for the resident, indicating that the diet change was not communicated effectively. Interviews revealed that a Licensed Vocational Nurse (LVN) had changed the diet order and communicated it to another LVN, who then passed the information to the Registered Dietician (RD) later in the day. The RD stated that she was not aware of the diet change and had not received any communication from the nursing department. This lack of communication resulted in the resident receiving the incorrect diet, contrary to the physician's order.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during the care of a resident with an indwelling catheter. The Centers for Medicare & Medicaid Services (CMS) issued new guidance effective April 1, 2024, requiring the use of EBP for residents with chronic wounds or indwelling medical devices during high-contact care activities. Despite this, the facility did not adhere to these guidelines during the care of a resident with a history of methicillin-resistant Staphylococcus aureus infection and severe cognitive impairment, who was dependent on staff for toileting hygiene and had an indwelling catheter. During an observation, it was noted that the staff, including a Certified Nurse Aide (CNA) and a Licensed Vocational Nurse (LVN), wore gloves and masks but did not wear gowns while providing catheter care to the resident. Interviews with the staff revealed a lack of awareness and understanding of the new EBP requirements, with some staff believing that gowns were only necessary if the resident had an infection. The Infection Control LVN was unaware of the new EBP guidelines, and the Director of Nursing and Administrator expected staff to wear the appropriate personal protective equipment (PPE) but did not ensure compliance.
Medication Transcription Error Leads to Unnecessary Drug Administration
Penalty
Summary
The facility failed to ensure a resident's drug regimen was free from unnecessary medications when nursing staff inaccurately transcribed a physician's order for milk of magnesia (MOM) onto the medication administration record (MAR). The order specified that MOM should be administered every third day as needed for constipation, but it was incorrectly transcribed and administered daily. This error resulted in the resident receiving seven unnecessary doses of MOM, which had the potential to compromise the resident's health and safety due to overuse. The resident, who was admitted with acute respiratory failure and hypoxia, was always incontinent and did not have constipation according to the Minimum Data Set (MDS) assessment. Despite this, the resident received MOM daily on multiple occasions in October 2023, leading to an unwitnessed fall and feces smeared on the floor near the bathroom on one occasion. The interdisciplinary team (IDT) noted the medication error and took steps to monitor the resident for adverse reactions to MOM. Interviews with licensed vocational nurses (LVNs) and the director of nursing (DON) revealed that the medication error occurred due to incorrect transcription by the admitting nurse. The facility's policy on physician orders, dated August 21, 2020, required a process to verify that all physician orders are complete and accurate, which was not followed in this case. The DON stated that a new system was implemented to review all medications with the floor nurse for accuracy after the incident. The resident's care plan was revised to discontinue MOM and monitor for diarrhea or complications, and physician orders were updated to discontinue all bowel medications and call for any constipation issues.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 508 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cupertino
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunny View Manor | 0.4 mi | ★★★★★ | 0 | 0 |
| Health Care Ctr At The Forum At Rancho San Antonio | 1.8 mi | ★★★★★ | 23 | 0 |
| Idylwood Care Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Sunnyvale Post-acute Center | 2.5 mi | ★★★★★ | 3 | 0 |
| Los Altos Post-acute | 2.9 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Cupertino Healthcare & Wellness Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.