Below 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 Post-acute Center during CMS and state inspections, most recent first.
A resident reported to a nurse that a CNA was rough while changing another resident's incontinent brief during the night shift. Despite the report, neither the CNA nor the LVN acknowledged receiving or acting on the allegation, and the DON was not informed until contacted by surveyors. The facility did not follow its policy requiring immediate reporting of suspected abuse to the administrator and authorities.
A resident with documented bilateral sensorineural hearing loss and observed hearing impairment was incorrectly coded as having adequate hearing on the MDS assessment. Staff interviews and medical records confirmed the resident's highly impaired hearing, but the MDS Coordinator verified that the assessment did not reflect this condition.
Surveyors observed an uncovered, overflowing blue garbage bin at the back door, which was confirmed by the IP to be in violation of facility policy requiring covered and non-overflowing containers. This failure resulted in improper disposal and storage of garbage.
A resident with hypertension, hypotension, and epilepsy received Losartan Potassium without documented verification that systolic blood pressure was above 100, as required by physician order. Both the LVN and DON confirmed the absence of documentation, and the resident later experienced a seizure and low blood pressure, resulting in hospital transfer.
A resident with hemiplegia, hemiparesis, epilepsy, muscle weakness, and moderate cognitive impairment was not accurately assessed for fall risk or assistance needs. Staff failed to provide required supervision during toileting, leaving the resident alone in the bathroom, which resulted in an unwitnessed fall. Documentation and interviews confirmed that the resident needed one-person assistance, but this was not provided, and assessments did not reflect the resident's true needs.
The facility failed to maintain safe and sanitary food storage and preparation conditions. Observations included expired mighty health shakes, lack of thermometers in refrigerators, moldy onions, improperly labeled tuna salad, and unclean ice machine filters. Additionally, a grease trap was uncovered and dirty, and plastic bins were improperly stored wet. These practices violated facility policies and FDA Food Code standards.
A long-term care facility failed to follow infection control practices, including improper hand hygiene by a CNA between residents on transmission-based precautions, outdated oxygen equipment maintenance, and lack of a water management program to prevent Legionella growth. Additionally, licensed nurses did not perform hand hygiene during medication administration, and an unlabeled urinal was found in a shared bathroom, increasing the risk of cross-contamination.
The facility's dish machine failed to reach the required temperature of 120°F for proper cleaning and sanitizing, with readings between 108°F and 115°F. Despite being aware of the issue for two months, the Dietary Aide, Dietary Director, Maintenance Director, and Administrator had not resolved the problem, potentially risking foodborne illness for 97 residents. The Registered Dietitian also reported the issue a month prior, but did not verify the temperature after maintenance adjustments.
Staff at the facility failed to maintain respect and dignity for three residents by addressing them as 'mama' instead of using their names or appropriate titles. A nurse and a CNA admitted to using the term out of habit, despite the facility's policy requiring respectful communication. The residents involved had varying degrees of cognitive impairment and medical conditions.
The facility failed to maintain sufficient nursing staff levels, with DHPPD falling below the required 3.5 hours and CNA DHPPD below 2.4 hours on multiple occasions. Interviews confirmed low staffing, especially on weekends, due to staff transitions, sick calls, and vacations.
The facility failed to ensure proper medication storage and labeling, with multiple expired medications found in refrigerators and medication carts. Insulin pens lacked resident-specific labels, and controlled medications were not properly managed after resident discharge. Medications and keys were left unattended on carts, violating facility policies.
The facility failed to ensure kitchen staff competency in food and nutrition services, with issues in dish machine temperature and sanitizer testing. A dietary staff member incorrectly recorded wash temperatures, and two aides were unable to properly test sanitizer levels. These failures risked improper sanitization of dishes and surfaces, potentially exposing residents to food-borne illness.
The facility's kitchen failed to maintain an effective pest control program, as evidenced by the presence of cockroaches and debris in the ice machine's air filter. Observations and interviews revealed that pest control treatments were not conducted frequently enough, and pest activity was noted in pest control invoices. The facility's policy required an ongoing pest control program to keep the building free of insects and rodents.
The facility failed to ensure call light devices were within reach for five residents, potentially delaying response to their needs. Residents with various medical conditions, including sepsis, Parkinson's disease, hemiplegia, and spinal stenosis, were observed unable to access their call buttons due to improper placement. CNAs confirmed these observations, acknowledging that call lights should be within easy reach, as per facility policy.
The facility did not provide the State LTC Ombudsman's contact information to residents, limiting their rights to confidentially discuss concerns. During interviews, residents reported the absence of this information, which was confirmed by the DON. The omission occurred after recent repainting, and the facility's policy indicated residents' rights to communicate with outside agencies.
The facility failed to make the most recent survey results readily accessible to residents and their families. During interviews, a resident and several others stated they did not know where to find the survey binder. An observation confirmed the binder was not visible in the lobby, and the front desk receptionist admitted it was stored in a drawer. The DON confirmed the binder should be easily accessible, as per the facility's policy on Resident Rights.
The facility did not follow its policy for advance directives and POLST forms for three residents. Sections related to advance directives were incomplete, and there was no evidence of signed directives or assistance offered. The Social Services Director confirmed these omissions, despite their role in ensuring completion and verification of such documents.
A resident's closet door in an LTC facility was broken and temporarily secured with tape, leading to an uncomfortable environment. Despite the resident's complaint, the issue was not reported to maintenance, and staff were unaware of the problem. The facility's policy requires maintenance to ensure rooms are in good repair, but this was not followed.
A resident with multiple health issues experienced a significant weight gain, but the MDS assessment inaccurately recorded this as a weight loss. The error was confirmed by the MDS Coordinator and Registered Dietitian, compromising the development of a proper care plan.
A resident with dementia and schizoaffective disorder was observed walking barefoot and shirtless in the hallway, contrary to their care plan which required supervision with ambulation and encouragement to wear appropriate clothing. The care plan also indicated the need for non-skid socks or shoes for safety. The DON confirmed these requirements were not met, highlighting a failure to implement the care plan interventions.
A facility failed to adhere to professional standards when a nurse applied a Lidocaine patch to a resident's shoulder instead of the lower back as ordered by the physician. Additionally, custom jewelry given by another resident was improperly stored in a narcotic box within a medication cart, contrary to facility policy.
A resident with a language barrier was not provided with communication aids or a baseline care plan upon admission, despite having conditions such as cerebral infarction and hemiparesis. The facility's policy required language assistance and a baseline care plan within 48 hours, but these were not implemented, affecting the resident's ability to communicate effectively.
A resident with multiple diagnoses and high fall risk experienced four falls without the facility updating their care plan or implementing new interventions. Despite the resident's falls, the facility did not revise the care plan or identify new contributing factors, leaving the resident unsupervised at times. The facility's policy required care plan revisions when conditions change, which was not followed.
A resident with morbid obesity and type 2 diabetes experienced a severe unplanned weight gain of 9.78% over three months due to the facility's failure to implement a comprehensive monitoring approach. Despite being on a cardiac diet, the resident's weight increased significantly without a care plan addressing the gain. Interviews revealed gaps in communication and follow-up, with the RD not interviewing the resident about his weight gain or food intake. The facility's policies on weight intervention and nutrition assessment were not followed, and necessary lab assessments were not conducted.
The facility failed to provide proper respiratory care for two residents. One resident's oxygen was not turned on after being transferred to an E-tank, and no care plan was developed for their oxygen use. Another resident's room lacked an 'Oxygen in Use/No Smoking' sign, and their care plan for oxygen use was also not developed.
The facility did not post nurse staffing information in a visible and accessible location for residents and visitors. Observations revealed that the information was missing from nurse stations and was placed behind the receptionist desk, making it difficult to see. Both the front desk receptionist and the staffing coordinator confirmed the lack of visibility and acknowledged the need for better placement.
A facility failed to limit the use of a PRN psychotropic medication for a resident with depression and Alzheimer's disease. The resident's order for Lorazepam, used for anxiety, was not restricted to a 14-day period as required by policy. The DON confirmed the oversight during a review, and no rationale for extending the order was documented.
The facility did not comply with regulations by failing to post the staffing waiver approval letter where it could be easily read by visitors and residents. Observations and interviews confirmed the letter was not displayed on the facility's cork board, despite the requirement for it to be posted adjacent to the facility's license and provided to residents before admission agreements.
A resident with major depressive disorder experienced misappropriation of property when a housekeeper cashed her checks without permission. The resident was alerted by her bank and informed the facility administrator. An investigation revealed the housekeeper's involvement, leading to their arrest. The facility offered a communal safe for valuables, which the resident declined, and no other secure storage options were provided.
The facility failed to conduct thorough investigations and document outcomes for several alleged altercations between residents. Investigation summaries lacked conclusions, and a witness interview was not documented, contrary to facility policy.
A facility failed to report an alleged abuse incident involving two residents to the appropriate agencies. A resident's family member reported that another resident threw a fan at their relative, who had severe cognitive impairment. Despite being informed, the facility's staff decided not to report the incident, concluding it was not intentional. This decision violated mandated reporting requirements.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to follow its abuse reporting policy and procedure for one of three sampled residents. An allegation was made by a resident that a male CNA was rough when changing his roommate's incontinent brief during the night shift. The resident reported this incident to the charge nurse, who asked for more details. The resident's clinical records indicated he had a diagnosis of post-traumatic stress disorder and an intact cognitive status, as evidenced by a BIMS score of 15. Interviews with the CNA and LVN assigned to the resident on the night in question revealed that both denied any knowledge or report of the alleged rough handling. The DON confirmed that the allegation was not brought to her attention by staff and stated that, had they been notified, they would have reported it to the appropriate authorities. Review of the facility's policy indicated that any suspicion of abuse must be reported immediately to the administrator and other officials as required by law. The failure to report the allegation as per policy had the potential to compromise the resident's safety.
Inaccurate MDS Assessment of Resident's Hearing Ability
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident when the resident's hearing ability was not properly coded. During observation and interviews, the resident was noted to be hard of hearing, did not have or use a hearing aid, and required questions to be repeated multiple times before responding. Both a CNA and an LVN confirmed the resident's hearing impairment. The resident's medical record documented a diagnosis of bilateral sensorineural hearing loss. However, the MDS assessment incorrectly coded the resident's hearing as adequate instead of highly impaired, as confirmed by the MDS Coordinator during a record review. This inaccuracy was contrary to the coding instructions in the CMS RAI Manual.
Improper Disposal and Storage of Garbage
Penalty
Summary
During an observation at the back of the facility's parking area, surveyors noted an uncovered blue garbage bin that was overflowing with refuse and positioned at the back door. The infection control preventionist confirmed that the garbage was not only overflowing but also lacked a cover at the time of inspection. Review of the facility's policy and procedure on food-related garbage and rubbish disposal indicated that all garbage containers should have tight-fitting lids and must be kept covered when stored or not in continuous use. The facility failed to adhere to this policy, resulting in improper disposal and storage of garbage.
Failure to Document Blood Pressure Prior to Antihypertensive Administration
Penalty
Summary
A deficiency occurred when the facility failed to administer medication in accordance with physician orders and professional standards of practice for a resident with diagnoses including hypertension, hypotension, and epilepsy. The physician's order specified that Losartan Potassium should be administered only if the resident's systolic blood pressure (SBP) was greater than 100. However, review of the Medication Administration Record (MAR) showed that the medication was given from 5/8/25 to 5/15/25 without documentation that the resident's blood pressure was checked and confirmed to be above the required threshold prior to administration. Both the LVN who administered the medication and the DON confirmed that there was no documentation of blood pressure being checked as required by the order. The resident experienced a change in condition on 5/15/25, including a seizure, unresponsiveness, and a recorded blood pressure of 80/54, which led to transfer to the hospital. The hospital discharge summary listed syncope and collapse as the principal diagnosis. Facility policy required that vital signs be checked and verified prior to medication administration when necessary, but this was not documented in the resident's records during the relevant period.
Failure to Accurately Assess and Supervise Resident Leads to Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including hemiplegia, hemiparesis following a stroke, epilepsy, muscle weakness, and difficulty walking, was not accurately assessed for fall risk and required assistance levels. The resident's assessments, including the Fall Risk Observation/Assessment and Admission/readmission Evaluation/Assessment, did not accurately reflect the resident's need for assistance with ambulation and toileting. Documentation and interviews confirmed that the resident required at least one-person assistance for transfers and toileting, and had moderate cognitive impairment. Despite these needs, staff failed to provide adequate supervision and assistance during toileting. A CNA assisted the resident into the bathroom but left the resident unsupervised after being asked to close the door and then left to answer another call light. The resident was subsequently found on the bathroom floor after an unwitnessed fall, stating that they had slid down from the commode. Interviews with the DON and DOR confirmed that the resident required one-person assistance and that staff should have remained nearby to provide the necessary support. Record reviews and staff interviews further revealed that the licensed nurse did not accurately assess the resident's fall risk or assistance needs, and seizure precautions were not properly noted. Facility policies required that residents unable to perform activities of daily living independently receive necessary services, and that fall risk factors be evaluated to minimize risk. These failures resulted in the resident experiencing an unwitnessed fall while unsupervised during toileting.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain safe and sanitary conditions for food storage and preparation, as evidenced by several observations during a survey. Two bins containing thawed mighty health shakes were found in a reach-in refrigerator with expired dates, and the Dietary Director (DD) acknowledged that the shakes were stored past their use date, which could lower their nutritional value. Additionally, the facility lacked internal thermometers in a three-door reach-in refrigerator and a walk-in freezer, which are necessary to monitor and maintain adequate food temperatures. Further deficiencies were noted in the handling and storage of food items. A large yellow onion with mold-like spots was found in the dry storage room, and a plastic container of tuna salad in the walk-in refrigerator lacked a use-by date. The DD confirmed the onion was rotten, and the Dietary Aide (DA) explained the tuna salad preparation process but did not record a cool-down temperature, which is required for safety. The ice machine's air filter was covered with debris, and the water filters for the ice machine and coffee maker were expired, indicating a failure to follow manufacturer's maintenance guidelines. Additional issues included a medium grease trap floor hole near the food production area that was uncovered and dirty, and ten large plastic bins were stacked wet in the dish machine area. These practices were contrary to the facility's policies and the FDA Food Code, which require clean and dry storage conditions. Interviews with the Administrator and Registered Dietitian revealed expectations for proper task completion, but the observed conditions indicated a lack of adherence to these standards.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices, as evidenced by multiple observations and interviews. A certified nursing assistant (CNA) did not wash hands between providing care to two residents on transmission-based precautions, which are intended to prevent the spread of germs. The CNA removed personal protective equipment after caring for one resident and only used hand sanitizer before attending to the next resident, despite both residents being infected with Methicillin-resistant Staphylococcus aureus (MRSA). This was confirmed by the director of nursing (DON) and the infection preventionist (IP), who acknowledged the necessity of handwashing between residents on such precautions. Additionally, the facility did not follow its policy regarding the maintenance of oxygen equipment. A resident's nasal cannula oxygen tubing was not changed after seven days as required, and another resident's oxygen concentrator filter was found with a grayish substance buildup, indicating it had not been changed weekly as per facility policy. The staff, including registered nurses and the DON, confirmed these oversights, acknowledging that the equipment should have been maintained according to the established schedule. The facility also lacked a comprehensive water management program to prevent the growth of Legionella bacteria, which can cause illness. Interviews with the maintenance directors and the IP revealed that they were unaware of the requirements for such a program, and no system was in place to monitor or control potential bacterial growth in the water supply. Furthermore, licensed nurses failed to perform hand hygiene before and after glove use during medication administration, and an unlabeled urinal was found in a shared bathroom, both of which could contribute to cross-contamination and infection spread.
Dish Machine Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the dish machine consistently provided accurate temperatures for cleaning and sanitizing dishes according to the manufacturer's guidelines. During an initial kitchen tour, it was observed that the dish machine did not reach the required temperature of 120°F for both the wash and rinse cycles, with temperatures recorded between 108°F and 115°F. Dietary Aide S confirmed these readings and stated that the machine had not been reaching the required temperature for the past two months, despite notifying the dietary manager and having the machine inspected by a technician. The Dietary Director, Maintenance Director, and Administrator were all aware of the issue, with the Maintenance Director having contacted the manufacturer to request a heat booster to increase the water temperature. The Registered Dietitian also noticed the malfunction a month prior and reported it to maintenance, but did not verify the temperature after adjustments were made. The facility's policy and the FDA Food Code require equipment to be maintained in proper working order, which was not adhered to in this case, potentially risking foodborne illness for the 97 residents consuming food at the facility.
Inappropriate Addressing of Residents by Staff
Penalty
Summary
The facility failed to maintain respect and dignity for three residents, identified as Resident 83, 91, and 249, by addressing them inappropriately. Registered Nurse F referred to Residents 83 and 91 as 'mama' during interactions. Resident 83, who has severe cognitive impairment due to dementia, was addressed as 'mama' by RN F while being redirected from entering another resident's room. Similarly, Resident 91, who has a moderate cognitive impairment and a history of cancer, was also addressed as 'mama' by RN F during a conversation in their room. RN F admitted to using the term 'mama' out of habit, acknowledging that residents should be addressed by their first names or with titles like Mister or Miss to maintain dignity. Certified Nursing Assistant G also addressed Resident 249 as 'mama' during an interaction. Resident 249, who has a moderate cognitive impairment due to Parkinson's disease and schizoaffective disorder, was addressed in this manner twice by CNA G. The Director of Nursing confirmed that staff should not use terms like 'mama' or 'honey' and should instead address residents by their preferred names. The facility's policy on dignity emphasizes that residents should be spoken to respectfully and addressed by their name of choice, not by labels or room numbers.
Insufficient Nursing Staff Levels
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff on a 24-hour basis, as evidenced by the Staffing Data Report submitted to CMS. The document review of the Census and Direct Care Services Hours Per Patient Day (DHPPD) from April through July 2024 revealed multiple dates where the actual DHPPD fell below the required 3.5 hours. Additionally, the certified nursing assistant (CNA) DHPPD was below the required 2.4 hours on several occasions. Interviews with the staffing coordinator, director of staff development, and director of nursing confirmed the low staffing levels, particularly on weekends during April to June 2024, due to staff transitions, sick calls, and vacations. The All Facilities Letter (AFL) 21-11 mandates a minimum of 3.5 DHPPD, with 2.4 hours provided by CNAs, as a requirement for skilled nursing facilities. The facility's waiver from the California Department of Public Health, valid from July 1, 2024, to June 30, 2025, also stipulated the maintenance of this minimum staffing level. Despite these requirements, the facility's staffing levels were insufficient, potentially affecting residents' care, health, and psychosocial well-being.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling, as observed during a survey. Multiple expired medications were found in medication refrigerators, including latanoprost eye solution, Augmentin, vancomycin, and Pneumovax 23, with expiration dates ranging from June to October 2024. Additionally, expired Lorazepam oral concentrate, Amoxicillin and Clavulanate potassium, and a probiotic supplement were identified. The Nurse Supervisor confirmed these observations, acknowledging that expired items should be discarded to prevent medical errors. Further inspection revealed two insulin pens in a medication refrigerator that lacked resident-specific labeling. The Nurse Supervisor confirmed that these pens should have been labeled with the resident's name and room number. An expired oral inhaler was also found in the active stock of a medication room, which the Nurse Supervisor confirmed should have been discarded. During a medication cart inspection, expired and discontinued controlled medications, including morphine, Hydro/Apap, and oxycodone, were found. These medications were associated with residents who had been discharged, and the Registered Nurse acknowledged that they should have been given to the Director of Nursing. Additionally, medication and keys were left unattended on medication carts, posing a risk of unauthorized access. The facility's policies and procedures, dated 2001, were reviewed, indicating that medications should be labeled, expired drugs destroyed, and medication compartments locked when not in use.
Deficiency in Kitchen Staff Competency and Sanitization Procedures
Penalty
Summary
The facility failed to ensure that the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice. A dietary staff member did not demonstrate the correct technique for testing the sanitation level on the dish machine or maintaining the correct wash temperature. The dish machine, identified as a low-temperature model, was observed to have a wash temperature ranging from 110 to 115 degrees Fahrenheit, below the required 120 degrees Fahrenheit. Despite this, the Dietary Aide recorded the wash temperature as 120 degrees Fahrenheit on the log sheet. The Dietary Director and Maintenance Director were aware of the issue, and the facility was waiting for a water heater booster to address the problem. The chlorine sanitizer level was also incorrectly assessed, with the Dietary Aide stating it should be 100-200 ppm, while the correct level should have been 50 ppm. Additionally, two Dietary Aides did not know how to properly test the sanitizer in the red bucket. One Dietary Aide admitted to not knowing how to test the sanitizer, possibly due to missing an in-service training. Another Dietary Aide incorrectly tested the sanitizer strength, reading it as 300-400 ppm, while the correct concentration should have been 150-400 ppm according to the manufacturer's label. The Dietary Director and Registered Dietitian acknowledged the staff's lack of knowledge in correctly testing the sanitizer solution. The facility's policies and job descriptions were reviewed, indicating that the kitchen staff should observe water temperatures during dishwashing cycles and ensure proper sanitization of work surfaces. The manufacturer's operating requirements for the dishwasher and sanitizer were also reviewed, highlighting the discrepancies in the staff's practices. These failures in staff competency had the potential to result in improperly sanitized resident dishes and food contact surfaces, exposing residents to food-borne illness.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the Food and Nutrition Services Department, specifically in the kitchen area. During an initial kitchen tour, a brown bug resembling a cockroach was observed moving across the floor in front of the tray line food preparation area. The kitchen staff member acknowledged seeing such bugs occasionally. The facility's Administrator mentioned that the kitchen was due for a quarterly fogging treatment to address pests like roaches. However, the Pest Company Technician indicated that only a spray-out treatment had been conducted a couple of months prior, and no fumigation treatment was performed. The technician suggested that more frequent treatments might be necessary. Further observations revealed that the ice machine's air filter screen was covered with black and gray debris, along with a dead brown bug resembling a cockroach. The Dietary Director and Maintenance Director confirmed the presence of debris and the dead bug, acknowledging that pests should not be present inside the ice machine. A review of pest control invoices from October 2023 through September 2024 showed findings of insect and rodent activity, with specific mentions of German roach activity in July and August 2024. The invoices included recommendations to seal cracks and crevices, empty trash regularly, and maintain cleanliness to prevent pest activity. The facility's pest control policy, dated May 2008, stated that an ongoing pest control program should be maintained to keep the building free of insects and rodents.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call light devices were within reach for five residents, potentially delaying response to their needs. Resident 250, admitted with sepsis, pneumonia, and diabetes mellitus, was observed unable to reach his call button, which was lodged between the mattress and headboard. Similarly, Resident 249, with Parkinson's disease and schizoaffective disorder, had her call button placed on the opposite side of her bed, out of reach, as confirmed by a certified nursing assistant (CNA). Resident 39, suffering from hemiplegia and vascular dementia, was found with her call button attached to a bedside drawer handle, making it inaccessible. A CNA confirmed this improper placement. Resident 25, diagnosed with hemiplegia and PTSD, had her call button on the floor, which she could not locate. This was also confirmed by a CNA, who acknowledged the button should be within reach. Resident 48, with spinal stenosis, was unable to reach her call light placed on an oxygen concentrator. A CNA confirmed the observation and acknowledged the call light should be accessible. The facility's policy mandates that call lights be within easy reach when residents are in bed or confined to a chair, which was not adhered to in these cases.
Ombudsman Contact Information Not Provided to Residents
Penalty
Summary
The facility failed to provide the State Long-Term Care Ombudsman's contact information to all residents, which limited their rights to have a confidential avenue to discuss concerns and resolve issues. During a group interview, one sampled resident and six non-sampled residents reported that they did not have access to the Ombudsman's contact information within the facility. A concurrent tour and interview with the Director of Nursing (DON) confirmed the absence of this information in any part of the facility. The DON explained that the omission occurred because the facility had recently been repainted, and they forgot to replace the Ombudsman contact information on the walls. The facility's undated policy and procedure on Resident Rights indicated that residents have the right to communicate with outside agencies, including the state long-term care ombudsman.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the results of the most recent survey were readily accessible to residents, family members, and legal representatives. During a group interview, one sampled resident and six non-sampled residents reported that they were unaware of where to find the survey binder containing the facility's survey results. An observation in the facility's lobby area confirmed that the survey binder was not visible. A follow-up interview with the front desk receptionist revealed that the survey binder was stored inside a drawer cabinet. The Director of Nursing confirmed these findings and acknowledged that the survey results binder should be placed on a table for easy access by residents and family members. The facility's policy and procedure on Resident Rights indicated that residents have the right to examine survey results, as guaranteed by Federal and State laws.
Failure to Complete Advance Directives and POLST Forms
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding advance directives (AD) and the completion of the Physician Order for Life-Sustaining Treatment (POLST) forms for three residents. Specifically, sections related to advance directives were not completed on the POLST forms for Residents 42, 16, and 26. Additionally, there was no documented evidence in the clinical records of these residents that an advance directive was signed by the resident or their responsible party, nor was there evidence that the facility offered assistance in establishing an advance directive prior to the survey period. During an interview and record review with the facility's Social Services Director (SSD), it was confirmed that the relevant sections of the POLST forms were not filled out for the three residents. The SSD acknowledged that it was the role of social services to ensure the POLST forms were completed and to verify the existence of an advance directive for each resident. The facility's policy indicated that staff should offer assistance in establishing advance directives if the resident or representative had not done so, and that copies of any executed advance directives should be maintained in the resident's medical record.
Failure to Maintain Homelike Environment Due to Unreported Maintenance Issue
Penalty
Summary
The facility failed to provide a homelike environment for Resident 69 due to a malfunctioning closet door that did not latch properly. This issue was observed during a visit to Resident 69's room, where the resident expressed dissatisfaction with the broken closet door, which had been temporarily secured with surgical tape by a housekeeper. Despite the resident's complaint to the housekeeper, no formal report was made to the maintenance department, and the issue remained unresolved. Interviews with facility staff, including the maintenance director, licensed vocational nurse, and certified nursing assistant, revealed a lack of awareness and communication regarding the broken closet door. The maintenance director confirmed that the issue was not logged in the maintenance log, which is the standard procedure for reporting repairs. The director of nursing acknowledged that staff should have reported the issue to maintenance. The facility's policy requires the maintenance department to ensure residents' rooms are in good repair, but this was not adhered to in this instance.
Inaccurate MDS Coding for Resident's Weight Gain
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident's weight gain, which compromised the ability to develop and implement a resident-centered care plan. Resident 78, who had multiple diagnoses including atrial fibrillation, Type 2 diabetes, and morbid obesity, experienced a severe weight gain of 9.78% over three months. However, the MDS assessment inaccurately recorded the resident's weight status, indicating a weight loss instead of a gain. During interviews and record reviews, it was confirmed that the MDS sections for weight gain were not coded correctly. The Minimum Data Set Coordinator and the Registered Dietitian both acknowledged the error, noting that the MDS should have reflected the resident's significant weight gain. The facility's policy requires accurate certification of the MDS, but this was not adhered to in this instance, leading to the deficiency.
Failure to Implement Care Plan Interventions for Resident
Penalty
Summary
The facility failed to implement care plan interventions for a resident, identified as Resident 13, who required supervision with ambulation, encouragement to wear shirts or gowns while not in rooms, and non-skid socks or shoes while walking in the hallways. The resident, who was admitted with multiple diagnoses including unspecified dementia, schizoaffective disorder, generalized weakness, and a history of falling, was observed walking barefoot and shirtless in the hallway. This observation was confirmed by a certified nursing assistant (CNA) who stated that the resident should wear a shirt for dignity and socks or shoes for safety. The care plan for Resident 13, dated 7/11/24, indicated the need for behavior monitoring and interventions to encourage wearing a shirt or gown and ensuring the use of non-skid socks or shoes. Additionally, a care plan implemented on 4/24/24 required supervision with ambulation due to generalized weakness. During an interview, the director of nursing (DON) confirmed that the care plan required supervision for ambulation, assistance with dressing and eating, and behavior monitoring. The DON acknowledged that the resident should not pour juice from the medication cart alone and should be supervised when walking in the hallway.
Improper Medication Administration and Storage Practices
Penalty
Summary
The facility failed to provide care and service in accordance with professional standards of practice for two residents. For Resident 15, the licensed nurse did not apply a Lidocaine patch as ordered by the physician. The resident, who had a moderate cognitive impairment, was supposed to have the patch applied to his lower back for pain management. However, during a medication pass observation, the nurse applied the patch to the resident's left shoulder after the resident indicated pain in that area. The nurse later confirmed that this was against the physician's order and subsequently obtained a new order to apply the patch to the shoulder. For Resident 92, the facility improperly stored custom jewelry in a narcotic box within a medication cart. The jewelry, made by the resident and given to staff as gifts, was not accepted by the staff and was intended to be returned to the resident's family. However, the items were stored inappropriately in the narcotic box, which is meant for controlled substances. Interviews with staff revealed that the items had been stored there for several days, contrary to the facility's policy, which requires such items to be submitted to social services in a timely manner.
Failure to Provide Communication Aids and Baseline Care Plan for Resident with Language Barrier
Penalty
Summary
The facility failed to provide adequate communication support for Resident 254, who had a language barrier and was unable to speak English. Despite being admitted with conditions such as cerebral infarction, hemiplegia, hemiparesis, and dysphagia, the resident's preferred language was not accommodated. Observations and interviews revealed that no communication aids were provided to the resident since admission, and staff did not utilize any aids to facilitate communication. The facility's policy required language assistance for individuals with limited English proficiency, but this was not implemented for Resident 254. Additionally, the facility did not develop a baseline care plan addressing the language barrier for Resident 254 within the required timeframe. The activities director confirmed that the baseline care plan was not developed and should have been implemented within 24 hours of admission. The responsibility for providing communication aids was shared between activities staff and nurses, but neither group ensured that the necessary aids were available to the resident. The facility's policy mandated a baseline care plan to be developed within 48 hours of admission to address immediate health and safety needs, but this was not adhered to in the case of Resident 254.
Failure to Update Fall Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to update the fall care plan and provide new interventions for a resident who was at high risk of falling. This resident, identified as Resident 6, had multiple diagnoses including polyneuropathy, COPD, pulmonary fibrosis, and unspecified asthma, which contributed to their high fall risk. Despite being assessed as high risk for falls, the facility did not revise the care plan or implement new interventions after each of the resident's four falls since admission. The resident's falls were documented in the clinical records, with the first fall occurring when the resident slipped on a piece of food while attempting to walk to the bathroom. Subsequent falls involved the resident sliding down from a wheelchair or bed, with one incident resulting in a skin tear. The interdisciplinary team (IDT) noted generalized weakness and the resident's diagnoses as contributing factors but did not identify any new contributing factors or develop new interventions to prevent future falls. Observations and interviews revealed that the resident was often left unsupervised, such as being seated in front of a medication cart without footwear, and the facility's director of nursing confirmed that the fall care plan was not updated or revised after each incident. The facility's policy required that care plans be revised when a resident's condition changes or when desired outcomes are not met, but this was not adhered to in the case of Resident 6.
Failure to Monitor Resident's Unplanned Weight Gain
Penalty
Summary
The facility failed to implement a comprehensive and systematic approach to effectively monitor a resident who experienced a severe unplanned weight gain of 9.78% over three months. The resident, who had a history of morbid obesity, type 2 diabetes, and cellulitis, was not adequately assessed or monitored for nutritional intake and weight changes. Despite being on a cardiac diet with no added sodium, the resident's weight increased significantly, and there was no evidence of a care plan addressing this unintentional weight gain. Interviews with the resident and staff revealed gaps in communication and follow-up. The resident was unaware of the significant weight gain and had not discussed dietary concerns with the dietitian. The Registered Dietitian (RD) acknowledged not interviewing the resident about his weight gain or food intake, including snacks from outside the facility. The Director of Nursing (DON) confirmed that the resident was not on a physician-ordered weight gain program and that the care plan should have addressed the weight gain and external food sources. The facility's policies on weight intervention and nutrition assessment were not followed. The RD had recommended protein supplementation and a comprehensive metabolic panel (CMP) lab assessment, but there was no follow-up to ensure these recommendations were implemented. The physician was unaware of the resident's BMI exceeding 35 and had not ordered the necessary labs, which could have aided in assessing the resident's nutritional status and preventing further weight gain.
Deficiencies in Oxygen Administration for Two Residents
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in oxygen administration. For Resident 6, who was admitted with conditions such as COPD, pulmonary fibrosis, and asthma, the oxygen was not turned on after being transferred to an E-tank. This oversight occurred when a restorative nursing assistant moved the resident to a wheelchair and connected the oxygen tubing to the E-tank, but did not ensure the oxygen was flowing at the prescribed rate of 3 liters per minute. The resident reported not receiving air for 15 minutes, and this was confirmed by RN F during an observation. Additionally, the facility did not develop a care plan for Resident 6's oxygen use, despite the resident's need for oxygen therapy due to their medical conditions. The Director of Nursing confirmed the absence of a care plan and acknowledged that it should have been developed to address the resident's oxygen needs. For Resident 10, who had diagnoses including Parkinsonism, chronic bronchitis, and COPD, the facility failed to post an 'Oxygen in Use/No Smoking' sign at the room entrance, as required by facility policy. The resident was on oxygen therapy at 2 liters per minute, but the necessary signage was missing. The Director of Nursing confirmed the oversight and also noted that a care plan for Resident 10's oxygen use was not developed, which should have included the oxygen rate ordered by the physician.
Nurse Staffing Information Not Clearly Posted
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a clearly visible and prominent place accessible to residents and visitors. During observations on multiple occasions, it was noted that nurse staffing information was not posted at nurse stations AA, BB, and CC. Additionally, the staffing information was found behind the receptionist desk in the lobby area, making it not easily visible to family members, visitors, or residents. The front desk receptionist confirmed that the information was not visible and acknowledged that it should be posted in an area visible to all. The staffing coordinator also confirmed that the information was placed behind the receptionist desk and agreed it should be more visible.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drugs. The resident, who was admitted with diagnoses of depression and Alzheimer's disease, had a physician order for Lorazepam to be administered as needed for anxiety. However, the order did not limit the use of Lorazepam to 14 days, as required by the facility's policy on psychotropic medication use. During an interview and record review, the Director of Nursing confirmed that the Lorazepam order for the resident was not appropriately limited to a 14-day duration, and there was no documented rationale for extending the order beyond this period.
Failure to Post Staffing Waiver Approval Letter
Penalty
Summary
The facility failed to comply with Federal and State laws and regulations by not posting the approval letter for a staffing waiver where visitors and residents could easily read it. During an observation on October 14, 2024, at 8:30 a.m., it was noted that the approval letter was not displayed on the facility's glass-covered cork board. In an interview on October 15, 2024, at 1:34 p.m., the staffing coordinator confirmed the existence of a staffing waiver. Further review and interviews with the director of nursing and the clinical consultant confirmed that the approval letter, dated July 12, 2024, was not posted as required. The letter specified that it should be posted immediately adjacent to the facility's license and that residents should be provided with a true copy of the approval letter prior to the execution of an admission agreement.
Misappropriation of Resident's Property by Housekeeper
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a housekeeper cashed out the resident's check without permission. The resident, who was admitted with a diagnosis of major depressive disorder, was alerted by her bank about unauthorized check cashing. The resident kept her checks in her purse and informed the facility administrator immediately upon receiving the bank's notification. The facility was notified by the resident's daughter about the unauthorized transactions, prompting an investigation. The facility reported the issue to the police, who advised waiting for more evidence. Upon obtaining copies of the checks, the facility identified them as matching an employee's information, leading to the housekeeper's arrest. The housekeeper was not allowed to work in the facility after the issue was discovered. The facility's social service director stated that the resident was offered the option to store valuables in a secure safe at the business office, which the resident declined. No other secure storage options were provided, such as a locked cabinet at the resident's bedside. The facility's policy emphasized the right of residents to be free from exploitation and the implementation of measures to safeguard resident valuables, which were not adequately followed in this case.
Failure to Conduct Thorough Investigations and Document Outcomes
Penalty
Summary
The facility failed to conduct thorough investigations and provide conclusive reports for several alleged altercations involving residents. Specifically, the investigation summaries for altercations between Residents 7 and 8, 9 and 10, 11 and 12, and 1 and 10 did not include outcomes or conclusions about whether the facility determined if the altercations occurred. This lack of conclusive documentation was confirmed during a review with the Administrator, who acknowledged that the investigation reports lacked conclusions. Additionally, the facility did not document an interview with a witness, Resident 14, who was present during an alleged altercation between Residents 3 and 4. The Case Manager confirmed that although Resident 14 was interviewed, the interview was not documented. The facility's policy requires that witnesses to incidents be interviewed and documented, and that follow-up investigation reports provide sufficient information to describe the results of the investigation.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the appropriate agencies, including the State Survey Agency. The incident involved a resident allegedly throwing a fan at their roommate, which was reported by the family member of the affected resident to the charge nurse on duty. Despite the report, the facility did not notify the State agency, potentially compromising the safety of the residents and violating mandated reporting requirements. The incident occurred when a resident's family member reported that another resident had thrown a fan at their relative. The affected resident had a severe cognitive impairment, while the alleged perpetrator had intact cognition but was diagnosed with acute transverse myelitis, PTSD, and an unspecified mood disorder. The facility's social services director and the DON were informed of the incident, but they decided it was not reportable because the alleged perpetrator denied the action, claiming the fan fell accidentally. The facility conducted an internal investigation, which included interviews with staff and both residents. The investigation concluded that the fan was not intentionally thrown, as the alleged perpetrator was asleep and not physically capable of throwing objects. The facility's administrator, who also serves as the abuse coordinator, decided not to report the incident to the State agency, as they believed no actual abuse occurred and no harm resulted from the incident. This decision was contrary to the facility's policy and state regulations, which require reporting any suspected or alleged abuse.
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 666 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) |
|---|---|---|---|---|
| Idylwood Care Center | 0 mi | ★★★★★ | 0 | 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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.