Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Idylwood Care Center during CMS and state inspections, most recent first.
Surveyors identified multiple infection control lapses, including improper storage and labeling of GT syringes and enteral feeding tubes, incorrect positioning of urinary catheter tubing and drainage bags, failure to clean and store respiratory equipment and wound care supplies, improper use and storage of nasal cannulas, failure to wear N95 masks correctly, dirty oxygen concentrator filters, and lack of stethoscope disinfection between uses. These actions and inactions by staff were confirmed through observation and interviews, and were not in accordance with facility policies or infection prevention standards.
Surveyors found an 18.75% medication error rate involving three residents. Errors included improper eye drop administration for a resident with glaucoma, incorrect preparation and administration of multiple medications via G-tube without proper flushing, and a missed dose of tamsulosin due to unavailability. Nursing staff did not follow physician orders or facility policies, resulting in multiple medication administration deficiencies.
Surveyors found that staff failed to properly label and store medications, including leaving expired medications in active stock, not dating opened vials and inhalers, and leaving a treatment cart unlocked and unattended. Staff and DON interviews confirmed these actions were not in line with facility policy or manufacturer guidelines.
Surveyors identified unsanitary conditions in the kitchen, including a can opener with brownish substances, food trays with black substances in the corners, and a food cart with whitish substances on its surfaces. These findings were confirmed by registered dietitians and indicated a failure to maintain clean food-contact and non-food-contact surfaces as required by facility policy and the FDA Food Code.
A resident with multiple chronic conditions was found self-administering expired OTC Vicks VapoRub without an IDT assessment or physician order. Nursing staff were aware of the resident's use, but no documentation or authorization for self-administration was present, contrary to facility policy.
The facility did not follow its policies for advance directives and POLST forms for three residents, resulting in incomplete documentation and a lack of evidence that staff verified, offered, or assisted with advance directives as required. Both the SSD and DON confirmed that staff should have completed these steps and ensured proper documentation.
A resident's personal and medical care instructions, including splint and feeding safety details, were posted openly above their bed in a shared room, making them visible to others. Both an RN and the DON confirmed that these instructions should have been covered to protect privacy, in accordance with facility policy.
A resident was observed receiving oxygen at 5 LPM via nasal cannula, contrary to the physician's order for 3 LPM to maintain oxygen saturation above 92%. Staff confirmed the discrepancy, and facility policy requires adherence to physician orders for oxygen therapy, including verification and documentation of the correct flow rate.
A resident with end-stage renal disease and a chest permacath for dialysis did not receive care consistent with professional standards when the facility failed to complete required dialysis communication records, did not develop a person-centered care plan, and did not ensure staff were trained or that emergency dialysis equipment was available.
A RN prepared finasteride, a hazardous drug, for a resident without wearing gloves, despite facility policy and clear labeling requiring protective equipment. Both the DON and pharmacist consultant confirmed that gloves should be used when handling this medication due to its absorption risk.
A resident with dysphagia and a physician order for a nosey cup did not consistently receive this adaptive equipment with meals, resulting in observed difficulty and spillage when drinking from a regular cup. Staff and dietary personnel confirmed the nosey cup was not always provided, despite clear documentation and facility policy requiring adaptive devices for those in need.
Two residents were not provided care in a manner that maintained dignity and respect. In one case, a maintenance staff member intervened in a behavioral incident by physically moving a resident's wheelchair, contrary to the resident's care plan and facility expectations. In another case, a resident's urinal containing urine was left on a bedside table next to food items, despite the resident's discomfort and facility policy prohibiting such placement. Both incidents were inconsistent with policies designed to protect resident dignity.
The facility failed to timely follow up on diagnostic results for two residents. One resident's DEXA scan results indicating osteoporosis were delayed in being reported to the physician, resulting in a delay in treatment. Another resident's DEXA scan referral was not documented or sent for several months. The facility's policy required prompt action on radiology orders, which was not followed.
Widespread Infection Control Lapses in Equipment Handling and Storage
Penalty
Summary
Multiple infection prevention and control deficiencies were observed throughout the facility, involving improper handling and storage of medical equipment and supplies. For example, a resident's bedside table contained an opened plastic bag with a gastrostomy (GT) syringe, and the same resident's urinary catheter tubing was positioned above the bladder and kinked, which was confirmed by a licensed vocational nurse (LVN) as incorrect. In another room, an opened and unlabeled GT syringe was found on a bedside table shared by two residents on isolation precautions, and an opened, unlabeled plastic bag with an enteral feeding tube was found touching an opened package of ointment on another resident's table. Additionally, a used spirometer mouthpiece with a dried yellowish substance was found touching the inside of a wash basin, and a dirty plastic garbage bag was observed touching a box of clean gloves on a resident's bed. Dakin's solution was also stored in the treatment cart without being cleaned after use during a wound dressing change. Further deficiencies included improper storage of nasal cannulas for two residents receiving oxygen therapy, as the cannulas were not in use and were left on surfaces such as a bed rail and a humidifier, which was acknowledged as an infection control issue by staff and the facility's infection preventionist. A nurse was observed wearing an N95 mask below her nose and mouth while preparing medications, despite a facility-wide requirement for proper mask use due to an influenza outbreak. Additionally, a resident's Foley catheter drainage bag was found on the floor, and staff confirmed it should have been anchored to the bed frame and not left on the floor. Enteral feeding tubes for three residents were not dated as required, and the filters on an oxygen concentrator for another resident were found to be dirty, contrary to facility policy and manufacturer recommendations for weekly cleaning. Finally, a nurse was observed failing to sanitize a stethoscope after use on a resident's gastrostomy tube before placing it back in the medication cart. This was confirmed by both the nurse and the Director of Nursing, who stated that the stethoscope should have been disinfected between uses. Facility policies and procedures reviewed during the survey supported the need for proper cleaning and disinfection of reusable medical equipment and supplies, as well as correct storage and labeling practices to prevent the transmission and spread of infection.
Medication Administration Errors and Policy Noncompliance
Penalty
Summary
Surveyors identified a medication error rate of 18.75% during medication administration observations, with six errors out of 32 opportunities involving three residents. One incident involved a nurse administering Brimonidine Tartrate eye drops to a resident with glaucoma without following proper technique. The nurse did not instruct the resident to look up, failed to pull down the lower eyelid to create a pocket, and instilled the drop directly into the inner corner of the eye. Additionally, the nurse did not apply gentle pressure to the tear duct after administration, and another staff member immediately wiped the eye, contrary to recommended procedures and the facility's policy. Another deficiency was observed during the administration of medications via gastrostomy tube (G-tube) for a resident. The nurse crushed multiple tablets together and mixed them with a powdered medication in a single cup, then administered the mixture through the G-tube without flushing between each medication. The nurse acknowledged that medications should have been crushed and administered separately with water flushes in between, as per physician orders and facility policy, to prevent drug interactions and tube obstruction. A third incident involved a resident not receiving a scheduled dose of tamsulosin due to the medication being unavailable in the facility. The nurse was unable to locate the medication and reported that it would be delivered later by the pharmacy. The medication administration record reflected that the dose was not given, and the Director of Nursing confirmed that the medication should have been available and administered as ordered. These failures demonstrate noncompliance with physician orders and facility procedures for medication administration.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors identified multiple failures in medication storage and labeling practices within the facility. During inspections of medication carts, expired medications such as Pepto Bismol were found in active stock, and opened multi-dose vials and inhalers lacked required open dates. Specifically, an opened insulin vial did not have an open date, a Wixela inhaler was not discarded after the recommended period, and a Breyna inhaler was missing an open date. Staff interviews confirmed that these medications should have been dated upon opening and discarded according to manufacturer guidelines, and that expired medications should not remain in use. Facility policy also required that opened medications be dated and expired or undated medications be separated from active stock. Additionally, a treatment cart was observed left unlocked and unattended in a hallway while a nurse performed a wound treatment in a resident's room. The nurse confirmed the cart was left unlocked, and the DON stated that carts should always be locked when not in use and within view of the user when unlocked. Facility policy supported this requirement, indicating that medication carts must be locked when out of sight or unattended.
Unsanitary Kitchen Equipment and Food Contact Surfaces
Penalty
Summary
Surveyors observed multiple sanitation deficiencies in the facility's kitchen during an inspection. A table-mounted can opener was found with brownish colored substances on its top and sides, which was confirmed by the registered dietitian as needing cleaning and to be free from rust. Additionally, six food trays, some of which were used to store loaves of bread and bowls, had black substances inside the corners. These trays were stored together inside a cart, and the presence of the black substances was confirmed by the registered dietitian. Further inspection revealed that a food cart parked inside the kitchen had whitish substances on the back and side surfaces. Both registered dietitians present acknowledged the observation. The facility's policy requires pots and pans to be properly sanitized, preferably using a dish machine, and the FDA Food Code 2017 mandates that food-contact and non-food-contact surfaces be clean and free from accumulations of residue or debris. These observed failures indicate that the facility did not maintain sanitary conditions in the kitchen as required.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A resident with diagnoses of congestive heart failure, chronic obstructive pulmonary disease, and depression was found to have an expired bottle of over-the-counter Vicks VapoRub on the bedside tray table. The resident reported self-administering this medication regularly for nasal use and stated that the nursing staff was aware of this practice. Review of the resident's records showed no documentation of an interdisciplinary team (IDT) assessment to determine the safety and appropriateness of self-administration, nor was there a physician order authorizing the resident to self-administer this medication. During interviews, a licensed vocational nurse confirmed the expired medication was present and that there was no physician order for self-administration. The director of nursing was unaware of the resident's self-administration and acknowledged that an IDT assessment and physician order should have been in place. Facility policy requires an IDT assessment and a physician order specifying which medications a resident may self-administer, but these steps were not completed for this resident.
Failure to Follow Advance Directive and POLST Procedures
Penalty
Summary
The facility failed to follow its own policies and procedures regarding advance directives (AD) and Physician Orders for Life-Sustaining Treatment (POLST) forms for three residents. For two residents, the POLST forms had incomplete sections regarding advance directives, and there was no documented evidence that the facility verified, offered, or assisted these residents in executing an AD. For the third resident, the POLST form indicated no advance directive, and again, there was no documentation that the facility offered or assisted with executing an AD. These findings were confirmed by both the social service director and the director of nursing, who acknowledged that staff should have completed the relevant sections and provided assistance as required. Record reviews showed that upon admission, the facility did not consistently ask residents about existing advance directives, nor did they ensure that copies were obtained and placed in the clinical record as outlined in their policy. Additionally, the admitting nurse did not always review the POLST form for completeness. The lack of documentation and incomplete forms demonstrate that the facility did not adhere to its established procedures for ensuring residents' rights regarding advance directives and life-sustaining treatment preferences.
Resident Privacy Breach Due to Uncovered Care Instructions
Penalty
Summary
A deficiency occurred when a resident's personal information and care instructions were posted on the wall above the head of their bed in a shared room, making the information visible to the roommate and any visitors. The posted instructions included details about the resident's splint use, such as the type of splint, its purpose, and specific instructions for wearing it, as well as feeding safety instructions that referenced the resident by name and outlined steps for safe feeding. These postings were observed during a survey, and the resident was awake at the time. During interviews, both a registered nurse and the Director of Nursing confirmed that the care instructions were posted in plain view and acknowledged that they should have been covered to maintain privacy and confidentiality. A review of the facility's policy on resident rights indicated that residents are entitled to personal privacy and confidentiality of their personal and clinical records, including medical treatment and accommodations. The failure to cover these care instructions resulted in a breach of the resident's right to privacy.
Oxygen Therapy Administered Above Ordered Flow Rate
Penalty
Summary
A deficiency occurred when a resident was observed receiving oxygen therapy at a rate of 5 liters per minute (LPM) via nasal cannula, despite a physician's order specifying oxygen administration at 3 LPM continuously to maintain oxygen saturation above 92%. Multiple observations confirmed the oxygen concentrator was set at 5 LPM, and this was acknowledged by a registered nurse who stated the order was for 3 LPM and the setting should not have been at 5 LPM. The Director of Nursing also confirmed that nurses are expected to follow the physician's order for oxygen administration. Review of the facility's policies indicated that staff are required to verify physician orders for oxygen therapy, adjust the flow rate as ordered, and document the flow rate, duration, and patient response. The failure to administer oxygen at the prescribed rate was not in accordance with these policies and procedures, and this discrepancy was identified through observation, interview, and record review.
Failure to Provide Safe and Appropriate Dialysis Care and Coordination
Penalty
Summary
The facility failed to provide dialysis services consistent with professional standards for a resident with chronic kidney disease stage 5 and dependence on renal dialysis. The facility did not properly coordinate communication with the dialysis center, as evidenced by incomplete Dialysis Communication Records (DCRs) on multiple dates. There was no documentation in the nurse's notes indicating that licensed nurses contacted the dialysis clinic to obtain special instructions or information about the resident's pre- and post-dialysis condition, weight, or other relevant details. Additionally, the facility's own policy required exchange of information and completion of communication forms before and after dialysis, which was not followed. The resident's care plan was not person-centered and included interventions inappropriate for the type of dialysis access in use. Specifically, the care plan referenced monitoring for thrill and bruit, which are not applicable to a chest permacath, the access device the resident had. The assistant director of nursing confirmed that the care plan did not reflect the resident's actual needs and status, and that it would need to be revised to be accurate and individualized. Staff interviews revealed that nurses had not received current training on caring for residents receiving dialysis, and there was no emergency dialysis kit available in the unit, medication room, medication cart, or crash cart. This lack of training and equipment further demonstrated the facility's failure to meet the needs of residents requiring dialysis care, as required by facility policy and professional standards.
Failure to Use Gloves When Preparing Hazardous Medication
Penalty
Summary
A Registered Nurse (RN) failed to follow facility policy and procedure by not wearing gloves while preparing finasteride, a medication labeled as a hazardous drug, for a resident. During a medication administration observation, the RN was seen preparing five medications, including finasteride, without using gloves, despite the medication blister pack being clearly marked with a red sticker indicating it was hazardous. The RN later confirmed awareness of the hazardous label and acknowledged that gloves should have been used during preparation. Interviews with the Director of Nursing (DON) and the Facility Pharmacist Consultant (FPC) confirmed that gloves are required when preparing finasteride, as per facility policy and due to the drug's potential risks. The facility's policy on hazardous drugs specifies that staff must use protective equipment, such as gloves, when handling these medications. The report also notes that finasteride can be absorbed through the skin and poses particular risks to women, especially those who are pregnant or may become pregnant.
Failure to Provide Prescribed Adaptive Eating Equipment
Penalty
Summary
A deficiency occurred when a resident with dysphagia, who had a physician order for a nosey cup to be provided with meals, did not consistently receive this adaptive equipment with their meal trays. During a lunch meal observation, the resident was given a regular plastic cup instead of the prescribed nosey cup, resulting in liquid spilling from the resident's mouth while drinking. Staff interviews confirmed that the nosey cup was not always provided with the resident's meal trays, despite clear documentation on the tray card and physician orders specifying its necessity. Multiple staff members, including certified nursing assistants, dietary staff, registered dietitians, and therapists, acknowledged that the nosey cup was essential for the resident's ability to drink liquids safely and comfortably. The facility's policy required that adaptive self-feeding devices be provided to residents who need them with each meal or snack, but this was not consistently followed for the resident in question. The failure to provide the prescribed adaptive equipment was directly observed and confirmed by staff interviews.
Failure to Maintain Resident Dignity During Behavioral Incident and Personal Care
Penalty
Summary
The facility failed to maintain resident dignity and respect in two separate incidents involving two residents. In the first incident, a maintenance staff member intervened during an episode where a resident with schizophrenia and bipolar disorder was banging on the nurse's station door. Despite the resident's care plan indicating the need for staff to explain procedures and allow time for adjustment, the maintenance staff repeatedly told the resident to stop, then physically pulled the resident's wheelchair backward. This action resulted in the resident striking the staff member. Interviews with facility staff, including the maintenance supervisor and DON, confirmed that maintenance staff are not expected to intervene in behavioral situations and that the approach taken was inappropriate. In the second incident, a resident with depression, anxiety, and moderate cognitive impairment was observed with a urinal containing yellow liquid placed on his bedside table next to food and drink items. The resident expressed discomfort with the urinal's placement but felt unable to change the situation. The activities director acknowledged the urinal should not have been on the table and removed it, later providing a holder for proper storage. The DON confirmed that urinals should not be stored on surfaces used for eating and should be emptied and stored in designated holders after use. Both incidents were found to be inconsistent with facility policies and training, which emphasize respectful, empathetic responses to resident behaviors and proper handling of personal care items to maintain dignity. The failures in these cases had the potential to affect the emotional well-being of the residents involved.
Failure to Timely Follow Up on Diagnostic Results
Penalty
Summary
The facility failed to follow up on diagnostic results in a timely manner for two residents, leading to deficiencies in care. For the first resident, who was admitted with schizophrenia and a benign neoplasm of the meninges, a DEXA scan was ordered to assess osteoporosis after a fracture was observed. Although the scan was conducted, the results indicating osteoporosis were not reported to the physician until several months later, resulting in a delay in starting the necessary medication. The physician expected the results within a month, but the facility only received and reported them nearly three months after the scan was performed. For the second resident, who was admitted with hemiplegia, hemiparesis, and hypertension, there was an order to schedule a DEXA scan. However, the referral for the scan was not documented or sent until several months later. The Director of Nursing confirmed the lack of documentation and stated that any referral should be documented when sent. The facility's policy required prompt noting and submission of radiology orders, which was not adhered to in these cases.
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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.
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Nursing homes near Sunnyvale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunnyvale Post-acute Center | 0 mi | ★★★★★ | 3 | 0 |
| Mountain View Healthcare Center | 1.5 mi | ★★★★★ | 3 | 0 |
| Los Altos Post-acute | 1.7 mi | ★★★★★ | 2 | 0 |
| Sunnyvale Gardens Post Acute | 1.7 mi | ★★★★★ | 0 | 0 |
| Camino Ridge Post-acute | 1.8 mi | ★★★★★ | 2 | 0 |
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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.