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 Sunnyvale Gardens Post Acute during CMS and state inspections, most recent first.
A resident with hepatic encephalopathy and other serious conditions did not receive prescribed Rifaximin due to the facility's inability to obtain it from the pharmacy. The medication was later found in the resident's drawer, having been brought upon admission but not documented. Facility staff failed to inform the physician of the missed doses, and the resident was later hospitalized and transitioned to comfort care.
A resident suffered first-degree facial burns after an e-cigarette exploded while she was on oxygen therapy in her room. The facility failed to inform residents of the smoking policy upon admission, and the admission packet lacked a smoking policy acknowledgment form. Interviews revealed that several residents were unaware of the smoking restrictions, and the facility's policy on electronic cigarettes was not adequately enforced.
The facility failed to ensure dietary support staff were competent in food and nutrition services, leading to incorrect sanitizer testing and thermometer calibration. One staff member did not know how to properly test the sanitizer solution, and two staff members failed to correctly demonstrate thermometer calibration. The registered dietitian admitted to not teaching the use of test strips, and recent in-services did not include a teach-back method.
The facility failed to maintain the privacy and dignity of five residents by posting personal care information in their rooms and not ensuring privacy during medical procedures. Notes with personal details were visible to visitors, and a resident's privacy was compromised during medication administration. These actions were against the facility's policy on dignity and privacy.
The facility failed to provide adequate supervision and fall management for residents identified as high risk for falls. Staff did not provide the required 1:1 supervision, and monitoring logs were absent for several residents. Observations revealed that staff were assigned to supervise multiple residents simultaneously, making it impossible to provide effective supervision. The Director of Nursing and the Administrator acknowledged the lack of 1:1 sitters and monitoring logs, compromising resident safety.
A facility failed to accurately account for controlled drugs and document medication administration for a resident with type 2 Diabetes Mellitus and Diabetic Neuropathy. Discrepancies were found between the Controlled Substance Accountability Sheet and the Medication Administration Records, with 13 oxycodone tablets unaccounted for. The Director of Nursing confirmed the findings, highlighting a breach in the facility's policy and procedures for medication administration.
A survey found a 10% medication error rate in an LTC facility. Errors included improper inhaler use instruction, failure to flush a G-tube between medications, and incorrect eye drop administration. Staff did not follow physician orders or facility policies, leading to these deficiencies.
The facility failed to ensure proper medication storage and labeling, with opened vials and bottles lacking open dates, latanoprost not refrigerated as required, and expired medications not removed. These issues were confirmed by the DON and LVNs, highlighting discrepancies with the facility's medication storage policy.
A long-term care facility failed to implement proper infection control practices, with staff neglecting hand hygiene protocols and improper maintenance of medical equipment. CNAs did not perform hand hygiene between resident interactions, and oxygen concentrators and nebulizer equipment were not maintained according to policy. Additionally, a wound nurse and an RN failed to follow hand hygiene protocols during care procedures.
A facility failed to follow its policy on self-administration of medication for a resident with multiple diagnoses, including COPD and anxiety disorder. Despite the resident's cognitive intactness, no assessment was conducted to determine the safety of self-administration. Eyedrops, one not prescribed, were found at the resident's bedside, contrary to facility policy. Both an LVN and the DON confirmed the lack of proper authorization for bedside medications.
The facility failed to develop comprehensive care plans for three residents with conditions such as depression, anxiety, Parkinson's disease, and low sodium levels. Despite being prescribed medications, these residents lacked care plans addressing their specific needs, as confirmed by the DON.
The facility failed to follow its enteral feeding policy for two residents, leading to potential complications. A resident with a G-tube did not have the tube placement or residual volume checked before flushing, contrary to policy. Another resident received medications via G-tube without placement verification. Both actions were against facility procedures, risking harm to the residents.
A resident with multiple sclerosis and a fracture had a bed rail installed without a documented physician's order or care plan. The facility did not attempt alternatives or assess entrapment risks before installation, contrary to its policy. Observations and staff interviews confirmed these deficiencies.
The facility failed to ensure staff competency in resident supervision, as a laundry aide was assigned to monitor residents without proper training or infection control adherence. The aide could not recall resident names, did not use a monitoring log, and handled call light buttons without hand hygiene. The DON confirmed aides should not provide direct care and must follow infection control protocols, which were not met, compromising resident safety.
A resident with a history of domestic violence and diagnoses including COPD, major depressive disorder, and anxiety disorder did not receive timely psychosocial support from social services. Despite the resident's request to see her psychiatrist and the care plan's indication for social services visits, there was no documentation of such visits. The Social Services Director and DON confirmed the lack of documented visits, which was against the facility's job description for providing necessary social services.
The facility failed to monitor a resident's edema while on Lasix and had duplicate oxycodone orders for another resident. The DON confirmed the lack of monitoring and duplicate orders, which could lead to adverse effects.
Three residents were administered psychotropic medications without prior non-pharmacological interventions or proper monitoring. One resident received anti-anxiety and antidepressant medications without documented attempts at non-drug interventions. Another was prescribed Abilify without behavior monitoring, despite a diagnosis of psychosis and Alzheimer's. A third resident was given Trazodone for insomnia without sleep monitoring. The facility's policies on non-pharmacological interventions and monitoring were not followed.
The facility failed to monitor and document antibiotic use for two residents, leading to incomplete records in the Infection Control Log. One resident with acute osteomyelitis was not documented for antibiotic use, and another resident's antibiotic regimen was inconsistently logged. These lapses were confirmed by the IP and DON, contrary to the facility's policy requiring comprehensive documentation.
The facility failed to ensure call lights were accessible and functional for four residents, impacting their ability to communicate with staff. A resident's call light was out of reach due to entanglement, while two residents had non-functioning call lights despite reporting the issue. Another resident's call light was repeatedly found out of reach, contrary to their care plan. Staff confirmed these issues, highlighting a lapse in adherence to facility policy.
A CNA improperly cleaned a resident's dentures using liquid hand soap instead of a denture cleanser or toothpaste, contrary to facility policy and professional recommendations. This was confirmed by the CNA and the IP, highlighting a failure to adhere to proper denture cleaning standards.
A resident at high risk for falls due to medical conditions fell and fractured their wrist after attempting to return to bed from the bathroom without the required assistance. Despite documented needs for supervision and assistance, the facility staff failed to implement the necessary precautions, leading to the incident. The facility's Director of Nursing acknowledged the lapse in care, and staff interviews confirmed the resident's need for supervision.
A resident's personal belongings were not secured or returned after being transferred to a hospital. The facility's policy requires belongings to be stored and released to the resident or their representative, but staff failed to document or locate the items. Interviews confirmed the oversight, with no signatures on the inventory form to indicate the belongings were returned.
A resident with osteoporosis and other medical conditions sustained fractures in the left hand, which the facility did not report as required. The facility's staff deemed the fractures as pathological due to osteoporosis and did not follow the policy to report injuries of unknown source to the necessary agencies.
The facility failed to document and address abuse allegations for three residents. Nursing documentation was missing for abuse allegations made by two residents, and there were no care plans for any of the three residents involved. Interviews confirmed the lack of documentation and care plans, indicating a failure to follow the facility's policies and procedures.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who did not receive a medication ordered by the physician. The resident, who had a history of hepatic encephalopathy, alcoholic cirrhosis of the liver with ascites, liver cell carcinoma, and dementia, was prescribed Rifaximin to be taken twice daily. However, the medication was not administered from July 26 to August 6, 2024, due to the facility's inability to obtain it from the pharmacy because of its high cost. The medication was later found in the resident's drawer, having been brought upon admission, but was not listed in the inventory of personal effects. Interviews with facility staff revealed that the medication was initially available but was not administered during the specified period. The facility's policies on administering medications and managing personal belongings were not followed, as the medication was not documented upon admission, and the physician was not informed of the missed doses. The resident was later hospitalized for respiratory failure and transitioned to comfort care before passing away, but the report does not link these events directly to the missed medication.
Failure to Implement Smoking Policy Leads to Resident Injury
Penalty
Summary
The facility failed to implement and inform all residents of their smoking policy upon admission, which led to a serious incident involving a resident. The resident, who was on oxygen therapy, suffered first-degree facial burns after an electronic cigarette exploded while she was in her room. This incident resulted in the resident being intubated and hospitalized. The survey revealed that the facility did not have a signed acknowledgment of the smoking policy in the resident's admission packet, indicating a lack of proper communication and enforcement of the policy. During the survey, it was observed that several residents were not informed of the facility's smoking policy upon admission. Interviews with residents confirmed that they were unaware of the prohibition of smoking within the facility. The Director of Nursing (DON) acknowledged that the admission packet did not include a smoking policy acknowledgment form, which contributed to the residents' lack of awareness about the facility's smoking restrictions. The facility's policy and procedure on smoking, including the use of electronic cigarettes, were not adequately enforced. The policy stated that electronic cigarettes should only be used in designated areas with supervision, and residents should be assessed for their ability to handle such devices safely. However, the resident involved in the incident was not properly supervised or informed about the risks associated with using electronic cigarettes while on oxygen, leading to the explosion and subsequent injuries.
Removal Plan
- Resident was transferred to the hospital for further evaluation and treatment as indicated.
- Resident's attending physician and emergency contact were notified of the incident. The resident is still currently in the hospital.
- Resident was provided emotional support and re-assurance of the facility staff in relation to the incident.
- Resident was offered psychology consult which she declined. Resident currently feels safe and has not brought up concerns to the facility staff.
- Residents have now been notified of the no smoking policy and a copy of the policy is available to the residents.
- All residents have the potential to be affected because of the use of oxygen at the facility. The facility leadership reviewed and observed all the residents on oxygen and all residents with history of smoking and found no other safety concerns such as smoking inside the room or other parts of the facility.
- All residents will be informed of the facility's non-smoking policy and will be educated on the complication of oxygen use and smoking (whether real cigarettes, e-cigarettes, or vapes) with signed confirmation which has been initiated.
- The Director of Nursing (DON), Director of Development (DSD) or designee will in-service all staff on the facility Smoking Policy to promote resident and staff safety.
- The Director of Nursing (DON), Administrator or designee will in-service all Admission Department on informing new admissions of the facility's non-smoking policy including the imminent risks of smoking while using oxygen or near oxygen products.
- To ensure ongoing compliance, the interdisciplinary team (IDT) will conduct at least a weekly review of the removal plan on ensuring residents' safety and will verify that new admissions were informed of the facility's Non-Smoking policy and were educated on the complication of smoking while using oxygen in the weekly IDT meetings. Any concerns will be discussed by the Administrator or designee for immediate resolution.
- The IDT will also review daily in the IDT meeting on weekdays if there are new patients with history of smoking and/or new patients that require oxygen use and verify that proper evaluation and safety interventions have been initiated.
- Moreover, the Administrator, Director of Nursing (DON) or designee will audit compliance in ensuring safety of residents including informing all new patients of the Non-Smoking policy and education on the complication of smoking while using oxygen or near oxygen products. This audit will be done weekly for 4 weeks, then monthly for 6 months. Any concerns or issues will be discussed in the daily stand-up meeting for immediate resolution and/or re-assessment by the interdisciplinary team.
- The Administrator or DON will provide a written quality assurance report that includes evaluation of the effectiveness of the plan of correction in the quarterly QAPI meeting for 6 months using pertinent compliance audit information and resolutions.
Deficiencies in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that dietary support staff were competent in carrying out the functions of the food and nutrition services department according to facility policy and standards of practice. One dietary support staff member did not know how to properly test the sanitizer in the red bucket, which is used for sanitizing food contact surfaces. During an observation, the staff member incorrectly tested the sanitizer solution, resulting in a concentration that was not at the correct level. The dietary manager verified the error, and the registered dietitian admitted that she did not teach staff how to use the test strips, only instructing them to test the solution when the sanitation water is changed. Additionally, two dietary support staff members failed to correctly demonstrate how to calibrate a thermometer used to test food temperatures. During an observation, one staff member attempted to calibrate a thermometer but did not achieve the correct temperature reading. The registered dietitian had recently conducted in-services on thermometer calibration and kitchen sanitation but did not include a teach-back method to ensure staff understood the procedures. The facility's policies and procedures outlined the correct methods for sanitation and thermometer calibration, but the staff did not adhere to these guidelines, potentially exposing residents to bacterial contamination.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain the dignity and privacy of five residents by posting personal information and care instructions in their rooms, visible to visitors. For Residents 29, 11, 100, and 76, notes containing personal care details were posted in their rooms, which could be seen by visitors, compromising their privacy. For instance, Resident 29 had notes about their hearing and communication needs, while Resident 11 had notes about their blanket and shower schedule. Resident 100 had notes about dietary restrictions and care instructions, and Resident 76 had a note about diaper usage. These postings were confirmed by RN U, who acknowledged that such information should not be openly displayed. Additionally, the facility failed to ensure privacy during medical procedures. RN L did not close the privacy curtain or door while administering medication through a gastric tube to Resident 64, leaving the resident's abdomen exposed. RN L admitted to forgetting to close the curtains, which was against the facility's policy of maintaining resident privacy during care. The Director of Nursing confirmed that privacy should have been maintained during such procedures. The facility's policy on dignity, revised in February 2021, clearly states that staff should protect confidential clinical information and ensure resident privacy during care. Despite this, the observations and interviews revealed that the facility did not adhere to these guidelines, potentially affecting the residents' emotional and psychosocial well-being.
Inadequate Supervision and Fall Management
Penalty
Summary
The facility failed to implement fall management and safety supervision policies for nine out of ten residents identified as high risk for falls. Specifically, staff did not provide the required 1:1 supervision for Residents 18, 76, and 106, who were identified as high risk of falling. Observations revealed that Resident 18 was left without supervision multiple times, despite a care plan intervention requiring close supervision up to 1:1. Similarly, Resident 76 was observed without a sitter or staff oversight, even though their care plan required close monitoring. Resident 106 was also left unsupervised on several occasions, despite a care plan indicating the need for supervision up to 1:1 every shift. The report further details that staff were assigned to supervise multiple residents simultaneously, making it impossible to provide adequate supervision. For instance, CNA V was assigned to supervise Residents 18, 28, 76, and 106, but was observed seated between Residents 18 and 28's doors, unable to effectively monitor all assigned residents. CNA T was also observed using a personal cell phone while supposed to be supervising multiple residents, further compromising the supervision required for high-risk residents. Additionally, the facility failed to maintain monitoring logs for Residents 26, 30, 90, 108, 116, and 122, who were also identified as high risk for falls. CNA D, assigned as a sitter for these residents, confirmed the absence of monitoring logs and expressed difficulty in preventing falls due to the high number of residents under her supervision. The Director of Nursing and the Administrator acknowledged the lack of 1:1 sitters and the absence of monitoring logs, which are essential for documenting resident activities and ensuring adequate supervision.
Failure to Document Controlled Drug Administration
Penalty
Summary
The facility failed to ensure accurate accountability of controlled drugs and proper documentation of medication administration for one resident. The resident, who was admitted with type 2 Diabetes Mellitus and Diabetic Neuropathy, had physician orders for oxycodone to manage pain. However, discrepancies were found between the Controlled Substance Accountability Sheet (CSAS) and the Medication Administration Records (MARs). On multiple occasions, nursing staff signed out oxycodone tablets on the CSAS but did not document their administration on the MARs. During an interview and record review, the Director of Nursing confirmed that 13 oxycodone tablets were unaccounted for. The facility's policy and procedures require nurses to document the administration of medications, including the time, dosage, and signature of the administering nurse. The failure to adhere to these procedures resulted in a lack of accountability for the controlled substances administered to the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 10% during a survey, with three errors occurring out of 30 opportunities. One incident involved a Licensed Vocational Nurse (LVN) who failed to instruct a resident on the proper use of an inhaler, Dulera, which is used to control asthma symptoms. The LVN did not guide the resident to breathe deeply, hold her breath, or wait the appropriate time between puffs, and also neglected to instruct the resident to rinse her mouth afterward, as per the physician's order and facility policy. Another error was observed when a Registered Nurse (RN) administered medications via a gastrostomy tube (G-tube) to a resident without flushing the tube with water between medications. The RN confirmed the oversight, acknowledging that she should have flushed the G-tube with water between each medication, as per the facility's policy and procedure. A third error involved an LVN administering eye drops to a resident. The LVN instilled the drops directly onto the iris without creating a pocket by pulling down the lower eyelid and did not instruct the resident to look up, contrary to the facility's policy. The Director of Nursing confirmed the correct procedure, which was not followed in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling, which was identified during an inspection of the medication refrigerator and medication carts. On one occasion, an opened multi-dose vial of insulin and two opened bottles of lorazepam oral solution were found without open date labels. The manufacturer's instructions for these medications require them to be discarded after a specific period once opened, which was not adhered to. Additionally, unopened latanoprost bottles were not stored in the refrigerator as required by the manufacturer's labeling, and expired medications were not removed from active stock. Further inspections revealed additional issues with medication storage and labeling. An unopened bottle of latanoprost was improperly stored at room temperature instead of being refrigerated, and an opened bottle of the same medication was not dated with an open date. Other medications, such as nitroglycerin tablets and a Trelegy inhaler, were found to be expired or undated, and a fluticasone propionate diskus was used beyond its recommended period after opening. These findings were confirmed by the Director of Nursing and Licensed Vocational Nurses, who acknowledged the discrepancies with the facility's policy and procedure for medication storage.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by multiple observations of staff neglecting hand hygiene protocols. Certified nursing assistants (CNAs) were observed setting up meal trays for residents without performing hand hygiene between tasks, even after touching their faces or other potentially contaminated surfaces. This was confirmed by the CNAs themselves and the infection preventionist, who stated that hand hygiene should be performed between resident interactions and after touching any body parts. Additionally, the facility did not maintain proper maintenance and storage of medical equipment. Oxygen concentrators for two residents had filters with grayish substance build-up, and staff were unsure of the protocol for changing these filters. Nebulizer masks and tubing for several residents were improperly stored, with some equipment not being changed for over a month, contrary to the facility's policy of changing them every seven days. The infection preventionist and director of nursing confirmed these observations and acknowledged the failure to adhere to the facility's protocols. Further deficiencies were noted in the handling of wound care and medication administration. A wound nurse did not change gloves between handling clean and dirty areas during wound treatment, and a registered nurse failed to perform hand hygiene between glove changes during medication administration. These actions were contrary to the facility's hand hygiene policy, which emphasizes the importance of hand hygiene in preventing healthcare-associated infections. The director of nursing confirmed the need for staff to follow proper hand hygiene protocols.
Failure to Implement Self-Administration of Medication Policy
Penalty
Summary
The facility failed to implement its policy and procedure on self-administration of medication for Resident 59, who was admitted with diagnoses including chronic obstructive pulmonary disease, respiratory disorders, major depressive disorder, and anxiety disorder. Despite having a Brief Interview for Mental Status (BIMS) score indicating cognitive intactness, there were no assessments performed to determine if Resident 59 was safe to self-administer medications. During an observation, two bottles of eyedrops were found on Resident 59's overbed table, one of which was given by a roommate and not prescribed by a physician. Licensed Vocational Nurse J confirmed that Resident 59 should not have medications at the bedside and acknowledged the lack of a physician's order for the tetrahydrozoline hydrochloride eyedrops. The Director of Nursing also confirmed that medications should not be at the bedside without proper authorization. The facility's policy requires that the interdisciplinary team determine if self-administration is clinically appropriate and safe, and any unauthorized medications found at the bedside should be returned to the nurse in charge. This oversight had the potential for unsafe and improper administration of medications.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, which included target symptoms, measurable objectives, and interventions. Resident 6 was admitted with diagnoses of depression and anxiety, and although prescribed medications such as Venlafaxine and Alprazolam, there were no care plans developed for these conditions. The Director of Nursing (DON) confirmed the absence of care plans during a review. Resident 106, diagnosed with depression and Parkinson's disease, was prescribed Nortriptyline and Ropinole, yet lacked corresponding care plans. Similarly, Resident 111, with a history of alcoholic cirrhosis and consistently low sodium levels, had no care plan addressing this issue. The DON acknowledged the absence of care plans for these residents, which was contrary to the facility's policy requiring individualized comprehensive care plans for each resident.
Failure to Verify G-Tube Placement Before Administration
Penalty
Summary
The facility failed to adhere to its policy and procedures for enteral feeding care for two residents, leading to potential complications. Resident 110, who was admitted with conditions including hemiplegia, hemiparesis, and dysphagia following a stroke, had a gastrostomy tube (G-tube) for enteral feeding. The Licensed Vocational Nurse (LVN G) did not check the placement of the G-tube or the residual volume before flushing it with water, which was against the facility's policy. The Director of Nursing (DON) confirmed that the correct procedure was to check the G-tube placement and residuals before flushing or administering medications. Similarly, for Resident 64, the Registered Nurse (RN L) administered medications via the G-tube without verifying its placement. RN L admitted to forgetting to check the placement and typically not doing so before medication administration. The facility's policy required checking the G-tube placement with a stethoscope before administering medications. These oversights had the potential to cause harm to the residents due to possible enteral feeding complications.
Failure to Follow Bed Rail Policy for Resident
Penalty
Summary
The facility failed to adhere to its policy regarding the use of bed rails for one resident. The resident, who was admitted with multiple sclerosis and a fracture of the right ulna, had a bed rail installed without a documented physician's order or a care plan for its use. Additionally, there was no documentation indicating that alternatives to bed rails were attempted prior to their installation, nor was there an assessment for the risk of entrapment. Observations revealed that the resident's bed had a 1/4 side rail in the upright position on the left side, with no rail on the right side. Interviews with facility staff, including the DON, confirmed the absence of necessary documentation and evaluations prior to the installation of the bed rail. The facility's policy requires an interdisciplinary evaluation and informed consent before using bed rails, which was not followed in this case.
Inadequate Staff Competency and Infection Control Practices
Penalty
Summary
The facility failed to ensure that staff had the necessary competencies to respond to residents' needs, as evidenced by the involvement of a laundry aide in resident supervision without proper training or adherence to infection control protocols. During an interview, the laundry aide, who was assigned to supervise four residents, could not recall the names of the residents and admitted to not using a monitoring log. The aide was observed handling call light buttons for two residents without performing hand hygiene or sanitizing the equipment, which is a breach of infection control practices. The Director of Nursing confirmed that laundry aides could serve as sitters but were not to engage in direct patient care and were expected to follow infection control procedures. The care plans for the two residents involved required close supervision, which was not adequately provided. The facility's job description for laundry aides and its policy on safety and supervision of residents emphasize the need for individualized, resident-centered safety interventions, which were not effectively communicated or implemented in this instance.
Failure to Provide Social Services Support for Resident with Domestic Violence History
Penalty
Summary
The facility failed to provide appropriate social services support for a resident with a history of domestic violence, resulting in a lack of timely psychosocial support. The resident, who was admitted with diagnoses including COPD, major depressive disorder, and anxiety disorder, had requested to see her own psychiatrist, but no follow-up was conducted. The resident confirmed that social services never visited her regarding her request, despite her history of domestic violence and the presence of anxiety due to her husband's impending release from jail. The resident's care plan indicated a need for social services to visit and evaluate as needed, but there was no documentation of such visits. The Social Services Director confirmed the absence of documented visits to address the resident's mood and acknowledged that the resident should have had weekly social services visits. The Director of Nursing also confirmed the lack of documented social services visits, which was contrary to the facility's job description for the Social Services Director, which required the provision of medically related social services to maintain the highest practicable well-being of each resident.
Failure to Monitor Medication and Duplicate Orders
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications. Resident 6, who was admitted with a diagnosis of heart failure, was prescribed Lasix to treat edema. However, the nursing staff did not monitor for edema as required, which was confirmed by the Director of Nursing (DON) during a review of the resident's records. The lack of monitoring for edema was a significant oversight in the resident's care plan. Resident 111, admitted with alcoholic cirrhosis and ascites, had duplicate orders for oxycodone 5 mg, a potent pain medication. The orders were dated differently, but both were active on the medication administration record (MAR). The DON confirmed the duplication and stated that one of the orders should have been discontinued. This oversight in medication management had the potential for excessive dosing and adverse effects.
Failure to Implement Non-Pharmacological Interventions and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications. Resident 59 was administered an anti-anxiety medication and two different antidepressants without any documentation of non-pharmacological interventions being attempted prior to the use of these medications. The resident had a history of physical abuse from her husband, which contributed to her anxiety and depression. The Director of Nursing (DON) confirmed that non-pharmacological interventions were only initiated during the recertification survey, indicating a lack of prior attempts to manage the resident's conditions without medication. Resident 63 was prescribed Abilify for delusional thoughts without any monitoring of the target behavior or documentation of non-pharmacological interventions. The resident was diagnosed with psychosis and Alzheimer's disease. Despite the prescription, there was no evidence of behavior monitoring related to the use of Abilify, and the DON confirmed the absence of such documentation. The resident was observed to be calm and smiling, with no reported behaviors that would necessitate the medication. Resident 6 was given Trazodone for depression manifested by insomnia, but there was no monitoring of the resident's sleep hours as required. The DON confirmed that the facility failed to monitor the number of hours the resident slept, which was a necessary component of evaluating the effectiveness of the medication. The facility's policies indicated the importance of using non-pharmacological interventions and monitoring, but these were not adhered to in the cases of the three residents.
Failure to Monitor and Document Antibiotic Use
Penalty
Summary
The facility failed to implement its Antibiotic Surveillance protocol effectively, as evidenced by the lack of monitoring and tracking of antibiotic use for two residents. Resident 331, who had a PICC line for intravenous antibiotic administration due to acute osteomyelitis, was not documented in the November 2024 Infection Control Log despite starting antibiotics on November 5, 2024. This oversight was confirmed during an interview with the Infection Preventionist (IP), who acknowledged the omission in the documentation process. Similarly, Resident 111, who was on Bactrim DS for SBP prophylaxis and Rifaximin for hepatic encephalopathy, had incomplete documentation in the facility's Infection Control Log. The use of Bactrim DS was only logged in July 2024, missing entries for the subsequent months, while Rifaximin was logged in October 2024 but not in November 2024. These discrepancies were verified by both the IP and the Director of Nursing (DON) during a review of the resident's records. The facility's policy, revised in December 2016, mandates that all antibiotic regimens be documented on the surveillance tracking form, which was not adhered to in these cases.
Deficiency in Call Light Accessibility and Functionality
Penalty
Summary
The facility failed to ensure that call lights were properly functioning and accessible for four residents, which could prevent them from communicating with staff for basic needs and emergencies. Resident 232's call light was found on the floor under the bed, out of reach, due to it being entangled with the bed/TV control. This was confirmed by a licensed vocational nurse who acknowledged that call lights should always be within reach. Residents 97 and 104 experienced non-functioning call lights. Resident 97's call light did not work for two weeks despite reporting it to staff, and the maintenance director was aware but had not fixed it. Similarly, Resident 104's call light sometimes failed to light up, and although the maintenance director was informed and planned to replace the wall panel, it was not done promptly, forcing the resident to rely on a roommate for assistance. Resident 122's call light was repeatedly found out of reach, either in a drawer or on the floor, despite a care plan intervention to keep it accessible. Various staff members, including a licensed vocational nurse, a certified nursing assistant, and a laundry aide, had to reposition the call light to make it accessible. The facility's policy emphasized the importance of keeping call lights within easy reach, but this was not consistently followed for Resident 122.
Improper Denture Cleaning Practices
Penalty
Summary
The facility failed to ensure that services provided were in accordance with standards of practice when a Certified Nurse Aide (CNA) used incorrect cleaning methods for a resident's dentures. During an observation, the CNA was seen removing the dentures from the resident's mouth and cleaning them with liquid hand soap and water in the restroom, instead of using a denture cleanser or toothpaste as per the facility's policy. This was confirmed by the CNA during the observation. An interview with the Infection Preventionist (IP) further confirmed that toothpaste should be used for cleaning dentures, not liquid hand soap. The facility's policy from 2017 and recommendations from The American College of Prosthodontists emphasize the use of a nonabrasive denture cleanser to effectively clean dentures and reduce harmful bacteria and fungi.
Failure to Provide Adequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident, leading to a fall and subsequent injury. The resident, who had a history of falls and was at high risk due to various medical conditions including osteoporosis and arthritis, required supervision and assistance for bed mobility, transfers, and toileting. Despite these needs being documented in the resident's care plan and assessments, the facility staff did not implement the necessary precautions and assistance. On the night of the incident, the resident attempted to return to bed from the bathroom without the required assistance and fell, resulting in a wrist fracture. The resident had previously called for help but did not receive the necessary support from the staff. The facility's Director of Nursing acknowledged that the staff failed to provide the supervision and assistance as outlined in the resident's care plan, which was crucial to prevent such falls. Interviews with the facility's staff, including the Director of Rehabilitation and a Certified Nursing Assistant, confirmed that the resident required supervision for mobility and toileting. The facility's policy on assisting with activities of daily living emphasized the need for appropriate support and assistance, which was not adhered to in this case, leading to the resident's fall and injury.
Failure to Secure and Return Resident's Personal Belongings
Penalty
Summary
The facility failed to adhere to its policy and procedure for securing and returning personal belongings of a resident who was transferred to an acute hospital and did not return. The resident, who had a significant family member assigned as their representative, was admitted to the facility and later discharged to the hospital following a fall. Upon discharge, the inventory of personal effects form lacked signatures from both the resident's representative and facility staff, indicating that the personal belongings were neither returned nor accounted for. Interviews with the resident's representative and facility staff revealed that the personal belongings could not be located, and there was no documentation of their return. The facility's social service assistant and director of nursing acknowledged the oversight, confirming that the belongings should have been stored and returned according to the facility's policy. The policy, revised in March 2017, mandates that personal belongings be released to the resident or their representative, with a signed release required for such items.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to implement its abuse policy and procedure for a resident when it did not report the resident's injury of unknown source. The resident, who had a history of osteoporosis and other medical conditions, was found with fractures in the left third and fourth metacarpals, which were not reported to the required agencies. The facility's interdisciplinary team and attending physician deemed the injury as likely a spontaneous pathological fracture due to the resident's osteoporosis, and thus, did not report it. The resident was admitted with several diagnoses, including sequelae of cerebral infarction, vascular dementia, and osteoporosis, which required substantial assistance with mobility and personal care. The resident's quarterly MDS assessment indicated severe impairment in daily decision-making and memory problems. Despite these conditions, the facility did not report the fractures as injuries of unknown source, as required by their policy. Interviews with facility staff, including the DON and administrator, confirmed that the fractures were not reported because they were considered pathological due to osteoporosis. The facility's policy required that all injuries of unknown origin be reported to local, state, and federal agencies, but this was not followed in this case, potentially compromising resident safety.
Failure to Document and Address Abuse Allegations
Penalty
Summary
The facility failed to maintain accurate and systematically organized documentation in accordance with accepted professional standards and practices for three residents. Specifically, there was a lack of nursing documentation for allegations of abuse made by Residents 1 and 2. Resident 1 alleged that a certified nursing assistant attempted to provide care despite the resident's refusal, but there were no progress notes documenting this incident. Similarly, Resident 2 reported feeling unsafe and threatened by a licensed vocational nurse, yet there were no nursing progress notes documenting these allegations. Additionally, the facility did not have care plans addressing the abuse allegations for Residents 1, 2, and 3. Resident 3's significant family member reported that a facility employee mishandled the resident, but there was no care plan in place to address this allegation. The absence of care plans for these residents indicates a failure to systematically organize and document the necessary interventions and responses to the allegations of abuse. Interviews with the facility's medical record director and the registered nurse unit manager confirmed the lack of documentation and care plans for the abuse allegations. Both staff members acknowledged that licensed nurses should have documented the allegations and initiated care plans to address them. The facility's policies and procedures for documentation and suspected resident abuse assessment were not followed, contributing to the deficiencies in maintaining accurate records and care plans for the residents involved.
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 657 citations issued within 25 miles in the last 12 months — including the 3 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 Sunnyvale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar Crest Nursing And Rehabilitation Center | 0.6 mi | ★★★★★ | 21 | 0 |
| Sunnyvale Post-acute Center | 1.7 mi | ★★★★★ | 3 | 0 |
| Idylwood Care Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Mountain View Healthcare Center | 2.8 mi | ★★★★★ | 3 | 0 |
| Camino Ridge Post-acute | 3 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sunnyvale Gardens Post Acute.
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.