Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cupertino Healthcare & Wellness Center during CMS and state inspections, most recent first.
A resident with multiple arthritis-related diagnoses and chronic pain had an active order for diclofenac sodium to be taken orally twice daily, but two scheduled doses were not administered because the medication was unavailable. The MAR reflected missed doses with a code directing to progress notes, which documented that the drug was not on hand during two consecutive medication passes. The resident reported missing two doses and stated he needed the medication for rheumatoid arthritis. An LVN and the DON confirmed the missed doses due to lack of medication availability, noting that the drug had been ordered from the pharmacy but not delivered in time, contrary to the facility’s policy requiring medications to be administered as prescribed.
A resident with severe cognitive impairment, muscle weakness, bipolar disorder, and a history of right rib fracture was being assisted with a brief change by a CNA who was not assigned to the resident. During care, the CNA held the resident’s wrist in a way reported as uncomfortable, leading the resident to become agitated and strike the CNA’s face. The CNA then slapped the resident on the right side of the face, an act witnessed by another CNA and later documented as a “medium slap” in clinical notes. The resident subsequently sat up and pointed to the affected wrist. The CNA involved had passed background screening and received abuse training at hire, and the facility’s abuse policy defined physical abuse as including hitting and slapping and required staff screening and training on abuse prevention.
A resident with multiple cardiac conditions, who was cognitively intact and able to swallow pills, was given all morning medications crushed and mixed with oatmeal by an LVN without a physician's order. The medications, including several that should not be crushed, were then administered by a CNA, which is outside the CNA's scope of practice. Facility policy and staff interviews confirmed these actions were not in accordance with professional standards.
A resident with complex urinary and renal diagnoses did not receive a physician-ordered urology consultation during their admission, despite multiple documented referrals and ongoing use of an indwelling catheter. Facility staff confirmed the referral was not completed before the resident's discharge, in violation of facility policy and physician orders.
A resident was left with oral medication unsupervised at bedside, contrary to professional standards. The LVN confirmed leaving the medication and acknowledged the error. The DON verified that the resident had no order for self-administration. The Medication Administration Record inaccurately documented the administration time. The resident had diagnoses including muscle weakness and paranoid schizophrenia.
The facility failed to provide appropriate social services for two residents after altercations. The Social Services Director did not perform or document required psychosocial assessments for the residents involved, despite acknowledging this responsibility. The Director of Nursing confirmed the necessity of a 72-hour psychosocial status check, which was not completed, potentially affecting the residents' well-being.
A resident, diagnosed with Ankylosing Spondylitis and cognitively intact, requested to change physicians, but the facility failed to assist. The SSA acknowledged the request but did not follow up, assuming the DON would handle it. This inaction violated the facility's policy supporting residents' rights to choose their attending physician.
A resident in an LTC facility did not receive necessary vision services, resulting in impaired vision due to the lack of prescription eyeglasses. Despite being on a referral list and having scheduled appointments, the resident was not seen by an eye doctor, and there was no documentation explaining the missed appointments. The resident's physician orders indicated a need for an eye health and vision consult, which was not fulfilled.
A resident with Alzheimer's and dementia, assessed as at risk for elopement, was able to leave the facility unsupervised due to a failure to implement the care plan intervention of marking the resident's wheelchair with a purple ribbon. The absence of this ribbon allowed the resident to transfer to another wheelchair without a wanderguard, leading to an elopement incident.
A resident, admitted for aftercare following joint replacement surgery, reported that his roommate grabbed his leg, causing distress and inability to sleep. Despite the resident's request to be moved, the facility did not separate the two residents immediately, violating the facility's abuse and neglect policy.
A resident who tested positive for COVID-19 was not isolated as required, leading to potential exposure in the facility. The resident left their room without a mask and entered the rehab gym, contrary to the facility's policy. Staff interviews confirmed the resident's non-compliance and the failure to adhere to infection control protocols.
The facility failed to properly store and label food items, as observed by a surveyor. Bell peppers with mold, undated cheese, and exposed diced ham were found in the kitchen, along with improperly sealed dry goods. Staff interviews confirmed these deficiencies, highlighting a lapse in following the facility's food storage policy.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in their medical records. Two residents with serious mental illnesses were inaccurately assessed as not having such conditions, despite state evaluations recommending specialized services. Another resident's discharge MDS incorrectly indicated a hospital discharge instead of a home discharge. Staff interviews confirmed these inaccuracies.
A resident with cognitive impairment and mental health diagnoses was observed yelling frequently, but the behavior was not included in their care plan. Facility staff, including a CNA, RN, and LVN, expected the behavior to be care planned. The facility's policy requires care plans to be updated based on assessed needs, but the resident's care plan lacked any mention of the yelling behavior, as confirmed by the Administrator and DON.
Two residents in an LTC facility did not receive proper nail care as required by their care plans. One resident, with a history of contractures and hemiparesis, and another with type 2 diabetes, were both observed with long fingernails despite needing assistance with personal hygiene. Staff interviews confirmed that nail trimming should have occurred on bath days, but this was not done, leading to deficiencies in their ADLs.
A resident with a history of dementia and mobility issues experienced an unwitnessed fall resulting in a head injury. The facility failed to determine the root cause of the fall, as the incident report was incomplete and staff provided inconsistent accounts. The DON acknowledged the need for better documentation and investigation.
A resident with severe cognitive impairment and a history of gastrostomy status was administered the wrong enteral feeding formula. The physician's order specified Nepro 1.8, but Jevity 1.2 was given instead. LVNs involved did not verify the formula against the order, and the error was confirmed by the facility's administration.
A resident with Alzheimer's and dysphagia was not served the prescribed pureed diet due to communication failures. Despite a physician's order to change the diet, the resident received a mechanical soft meal. The LVN communicated the change to another LVN, who informed the RD, but the RD was unaware of the change, leading to the incorrect meal being served.
A facility failed to implement enhanced barrier precautions (EBP) during catheter care for a resident with an indwelling catheter and severe cognitive impairment. Despite new CMS guidelines requiring EBP for residents with indwelling devices, staff wore gloves and masks but not gowns. Interviews revealed a lack of awareness and understanding of the new EBP requirements among staff, including the Infection Control LVN. The Director of Nursing and Administrator expected compliance with PPE use but did not ensure it.
A resident received unnecessary doses of milk of magnesia (MOM) due to a transcription error by nursing staff, leading to potential health risks. The resident, who was always incontinent and did not have constipation, was administered MOM daily instead of every third day as needed. This error resulted in an unwitnessed fall and required the interdisciplinary team to monitor for adverse reactions.
Failure to Ensure Availability of Prescribed Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident when prescribed diclofenac sodium was not available for administration for two scheduled doses. The resident had multiple arthritis-related diagnoses, including ankylosing spondylitis of the spine, rheumatoid arthritis, osteoarthritis, other chronic pain, and arthropathy, and was cognitively intact with a BIMS score of 15. The resident had an active order for diclofenac sodium 25 mg, three tablets by mouth twice daily for rheumatoid arthritis. The MAR for the relevant period showed code 9 entries for the scheduled diclofenac doses, indicating "Other/See Progress Notes" for one evening and one morning administration time. Nursing progress notes documented that during medication pass on one evening, the resident’s prescribed diclofenac was unavailable, and that the medication remained unavailable the following morning. In an interview, the resident confirmed missing two doses of diclofenac sodium and stated he badly needed the medication for rheumatoid arthritis, adding that nurses did not give the medication and blamed the pharmacy. An LVN confirmed not administering the morning dose because the medication was not available and stated that nurses should order medications several days before they are consumed and that the pharmacy should deliver within 24 to 48 hours. The DON stated nurses should order medications three days prior to running out and confirmed the resident missed two doses because the medication was not available, further stating that diclofenac had been ordered from the pharmacy on two prior dates and was not delivered on time. The facility’s medication administration policy required medications to be administered as prescribed to ensure compliance with dose guidelines.
Failure to Protect Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by staff. The resident was admitted with diagnoses including muscle weakness, bipolar disorder, and a right rib fracture sequela, and had a BIMS score of 5 indicating severe cognitive impairment. Nursing notes documented a change in condition monitoring for swelling to the left radial wrist and skin discoloration on the left inner thigh, and an x-ray later showed mild degenerative joint disease of the left wrist. During personal care, a CNA who was not assigned to the resident assisted with a brief change. According to the facility-reported incident, the resident became agitated and scratched the CNA’s face, after which the CNA slapped the resident on the right side of the face. An eInteract SBAR summary documented that the assigned CNA witnessed the other CNA slap the resident on the right side of the face with a “medium slap” while attempting to provide care. In an interview, the witnessing CNA stated that the assisting CNA insisted on holding the resident’s wrist despite being told it was uncomfortable for the resident, that the resident freed a hand and hit the CNA’s face, and that the CNA then hit the resident back in the face and left the room. The resident then sat up in bed and pointed to the wrist. The CNA who committed the abuse had been hired several months earlier, had undergone background screening, and had last received abuse training at orientation. The facility’s abuse prevention and management policy defined physical abuse as including hitting and slapping and required screening and training of staff on abuse prevention and understanding resident behaviors that may increase the risk of abuse.
Improper Medication Administration and Scope of Practice Violation
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) crushed all of a resident's morning medications, mixed them with oatmeal, and left them at the resident's bedside. The resident, who had a history of myocardial infarction, atrial fibrillation, chronic systolic heart failure, and hypertension, was cognitively intact and had no documented swallowing difficulties. According to interviews and record review, the resident typically took medications whole with water and had not requested for them to be crushed. The LVN did not obtain a physician's order before crushing the medications, which included several that should not be crushed, such as enteric-coated aspirin, isosorbide mononitrate extended-release, and pantoprazole delayed-release tablets. A certified nursing assistant (CNA) subsequently administered the oatmeal mixed with crushed medications to the resident, despite this being outside the CNA's scope of practice. The CNA confirmed that she assisted the resident with breakfast and provided the oatmeal with medications after the LVN left the room. The resident noticed the altered taste and reported the issue to a family member, who also confirmed that the CNA had given the medication-laced oatmeal. Facility policy states that only licensed nurses are to administer medications and that a physician's order is required to crush medications. Interviews with staff, including the director of staff development and the director of nursing, confirmed that the CNA should not have administered medications and that the LVN misinterpreted the resident's needs. The facility's own policies and in-service training materials reinforce that medication administration is the responsibility of licensed nurses and that CNAs are not permitted to give medications to residents.
Failure to Provide Timely Urology Consultation as Ordered
Penalty
Summary
A deficiency occurred when a resident with diagnoses including end stage renal disease, obstructive and reflux uropathy, and urinary retention did not receive a urology consultation as ordered by the physician. The resident was admitted with an indwelling urinary catheter, and physician orders and progress notes repeatedly documented the need for a urology referral and evaluation. Despite these orders, the resident was not seen by a urologist during their stay, and the referral remained pending throughout their admission. Interviews with facility staff, including the DON and Nurse Supervisor, confirmed that the urology consult was ordered but not completed, with the Nurse Supervisor stating that referrals typically take a month or more to process. The resident ultimately was discharged against medical advice without having received the required urology evaluation. Facility policy indicated that the Director of Social Services, with assistance from nursing staff, was responsible for arranging such referrals, but this process was not completed in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that treatment and care were provided in accordance with professional standards of practice when a resident was left with oral medication to be taken unsupervised at bedside. During an observation, a medicine cup with two white capsules and a plastic cup of water were found on the resident's bedside table. The resident confirmed that the nurse left the medication for her to take. A Certified Nurse Aide verified the presence of the capsules and called the resident's nurse. The Licensed Vocational Nurse (LVN) confirmed that she left the medications and acknowledged that it was not appropriate to leave medications at the bedside without supervision. The Director of Nursing (DON) confirmed that medications should not be left at the bedside without a doctor's order for self-administration, which the resident did not have. A review of the Medication Administration Record showed that the medication, Gabapentin, was documented as administered at a specific time, but the LVN confirmed she did not administer it at that time. The resident's clinical record indicated diagnoses of muscle weakness, paranoid schizophrenia, and major depressive disorder. The facility's policy required that medications be given by the licensed nurse preparing them and documented accurately, which was not followed in this instance.
Failure to Conduct Psychosocial Assessments After Altercations
Penalty
Summary
The facility failed to provide sufficient and appropriate social services for two residents following resident-to-resident altercations. The Social Services Director (SSD) acknowledged her responsibility to conduct psychosocial and emotional assessments for residents involved in altercations and to document these assessments in the residents' electronic charts. However, the SSD did not perform or document these assessments for Resident 10 and Resident 7 after their respective incidents. Resident 10 was involved in an altercation with another resident, where Resident 10 allegedly tapped the other resident's legs, but no follow-up assessment was documented. Similarly, Resident 7 was allegedly grabbed and kicked by another resident, yet no psychosocial assessment was recorded. The Director of Nursing (DON) confirmed that a 72-hour psychosocial status check should be conducted by social services and documented in the resident's chart. The facility's job description for the Social Services Coordinator outlines the responsibility to assess the psychosocial, mental, and emotional needs of residents and communicate these needs to relevant parties. The lack of documentation and follow-up assessments for the involved residents indicates a failure to adhere to these responsibilities, potentially impacting the residents' psychosocial well-being.
Failure to Honor Resident's Physician Choice
Penalty
Summary
The facility failed to honor a resident's right to choose their attending physician, as evidenced by the actions and inactions of the social services assistant (SSA). The resident, who was cognitively intact and diagnosed with Ankylosing Spondylitis of the Spine, expressed a desire to switch physicians approximately two months prior to the survey. The SSA acknowledged the resident's request and believed she had informed the director of nurses (DON) but did not follow up on the matter. During interviews, the SSA admitted to not knowing the procedure for changing physicians and assumed the DON would handle it. The facility's policy, which supports residents' rights to choose their attending physician, was not adhered to, leading to a potential compromise of resident rights.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to provide necessary vision services for a resident, resulting in impaired vision due to the lack of prescription eyeglasses. The resident, who had clear speech and adequate vision with corrective lenses as per the Minimum Data Set assessment, reported that their glasses were taken and no assistance was provided to make an appointment for new ones. Despite a referral being sent to an eye doctor, the resident was not seen on the scheduled dates, and there was no documentation explaining why the appointments on 4/29/24 and 7/9/24 did not occur. Interviews with the Social Services Associate and Social Services Director revealed that the resident was on the referral list but was not evaluated. The resident continued to express concerns about not having an appointment for their glasses. Although an appointment was eventually scheduled, the resident could not be seen because they were on a gurney. The physician's orders from 11/15/2022 indicated a need for an eye health and vision consult, highlighting the ongoing issue of unmet vision care needs.
Failure to Implement Elopement Care Plan for Resident
Penalty
Summary
The facility failed to implement the elopement care plan for a resident diagnosed with Alzheimer's disease and dementia, who had a history of wandering and falling. The resident was assessed as being at risk for elopement, with a score indicating such risk. Despite this, the resident was able to transfer herself to another wheelchair without a wanderguard and elope from the facility, reaching a nearby street corner. This incident occurred because the care plan intervention, which required a purple ribbon to be tied on the resident's assigned wheelchair to ensure staff could identify it, was not followed. During an observation, it was noted that the purple ribbon was missing from the resident's wheelchair, contrary to the care plan. Interviews with the LVN and DON revealed that the staff were aware of the resident's elopement risk and the care plan intervention involving the purple ribbon. However, the intervention was not consistently implemented, as evidenced by the absence of the ribbon during the observation. The DON confirmed that the care plan required the ribbon to be on the wheelchair and acknowledged that the staff should adhere to the care plan to ensure the resident's safety. The facility's policy on wandering and elopement emphasized the importance of identifying residents at risk and implementing measures to minimize such risks, which was not effectively executed in this case.
Failure to Separate Residents After Incident
Penalty
Summary
The facility failed to ensure a resident was free from abuse when two residents were not separated after an incident. Resident 1, who was admitted for aftercare following joint replacement surgery, reported that his roommate, Resident 2, grabbed his leg on the first night of admission. Despite Resident 1's distress and request to be moved, the facility staff did not separate the two residents immediately, resulting in Resident 1 feeling terrified and unable to sleep. The Director of Nursing acknowledged that the residents should have been separated sooner. The Nursing Supervisor's review of progress notes indicated that Resident 1 was upset and called 911 after his roommate's actions. The facility's policy on abuse and neglect required immediate separation of residents in such situations, but this was not adhered to until later in the morning after an interdisciplinary care team meeting.
Failure to Isolate COVID-19 Positive Resident
Penalty
Summary
The facility failed to implement effective infection prevention and control strategies to prevent the spread of COVID-19 when a resident, who tested positive for COVID-19, was not isolated as required. The resident, identified as Resident 3, was admitted with a positive COVID-19 test and was supposed to be under contact/droplet precautions for 10 days. However, the resident left their room without a mask and entered the rehab gym, which was against the facility's policy that restricted movement of COVID-positive residents to their rooms unless for medically necessary purposes. Interviews with staff and residents revealed that Resident 3 was in the gym for an extended period without a mask, and staff had to intervene to escort the resident back to their room. The Infection Preventionist confirmed that Resident 3 was non-compliant and combative, and despite consulting with the county infection prevention consultant, the resident was not kept in isolation as recommended. The facility's policy clearly stated that residents on transmission-based precautions should remain in their rooms, highlighting a failure in adherence to the established infection control protocols.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to its food storage policy, resulting in several deficiencies related to the handling and storage of food items. During an observation, a surveyor found improperly stored food items in the kitchen, including bell peppers with a black fuzzy substance and fluid seeping from the container, undated bags of cheese, and an undated bag of diced ham exposed to air in the walk-in freezer. Additionally, containers of dry milk, lima beans, and rice were found open to air in the dry storage area. These findings indicate a failure to label, date, and properly seal food items as required by the facility's policy. Interviews with facility staff, including a Dietary Aide, Registered Dietician, Dietary Supervisor, Director of Nursing, and the Administrator, confirmed the deficiencies. The Dietary Aide acknowledged that the bell peppers were spoiled and should have been discarded earlier, and the cheese should have been labeled with an opened and use-by date. The Registered Dietician and Dietary Supervisor emphasized the importance of sealing food items and labeling them correctly. The Director of Nursing and Administrator reiterated the facility's policy requirements for labeling and sealing food items, highlighting a lapse in following established procedures.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their medical records. Resident #50, who was admitted with a history of paranoid schizophrenia, schizoaffective disorder, and major depressive disorder, was inaccurately assessed in the MDS as not having a serious mental illness, despite a prior state evaluation recommending specialized services. Similarly, Resident #65, with diagnoses of major depressive disorder and adjustment disorder, was also inaccurately assessed in the MDS, contradicting a state evaluation that recommended specialized services. Interviews with the MDS Nurse, Administrator, and Director of Nursing confirmed these inaccuracies. Resident #159's discharge MDS was also found to be inaccurate. The resident, who had a history of Parkinson's disease and type two diabetes, was recorded as being discharged to a short-term general hospital, whereas the discharge planning review indicated the resident was discharged to a private home with home health services. The MDS Nurse and Director of Nursing acknowledged the error, emphasizing the importance of correct coding for tracking residents in emergencies. The Administrator also highlighted the significance of accurate discharge MDS coding.
Failure to Address Resident's Yelling Behavior in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the yelling behavior of a resident with a medical history of mild cognitive impairment, schizophrenia, and major depressive disorder. The resident was admitted on December 20, 2023, and a quarterly Minimum Data Set (MDS) assessment on March 28, 2024, indicated severe impairment in cognitive skills for daily decision-making, but did not document any behaviors. Despite this, observations on May 27 and May 29, 2024, noted the resident yelling intermittently and unintelligibly. Interviews with facility staff, including a CNA, RN, and LVN, revealed that the resident's yelling was a known behavior, and staff expected it to be included in the care plan. The facility's policy on Comprehensive Person-Centered Care Planning, revised in November 2028, mandates that care plans be updated based on assessed needs. However, the resident's care plan lacked any mention of the yelling behavior, which was confirmed by the Administrator and the Director of Nursing during an interview on May 31, 2024. They acknowledged that the behavior should have been care planned.
Failure to Provide Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, leading to deficiencies in their activities of daily living (ADLs). Resident #20, who was admitted in 2015 and has a medical history of contractures and hemiparesis following a cerebral infarction, was observed multiple times with long fingernails despite being dependent on staff for personal hygiene. The resident's care plan required staff to check and trim nails on bath days and as needed, but observations and interviews revealed that this was not done. The resident expressed a desire to have their nails trimmed, indicating that the staff did not fulfill this aspect of care. Similarly, Resident #93, admitted in 2023 with a history of type 2 diabetes and requiring substantial assistance for personal hygiene, was also found with long fingernails. The care plan for this resident also required nail trimming on bath days and as necessary. Interviews with staff, including CNAs and LVNs, confirmed that the nails should have been trimmed during the resident's bath/shower days. Despite the facility's policy and staff expectations, the necessary nail care was not provided, as confirmed by the Director of Nursing and the Administrator.
Failure to Determine Root Cause of Resident Fall
Penalty
Summary
The facility failed to determine a root cause for a fall involving a resident, which was a deficiency in their fall management program. The resident, who was admitted with a medical history of adult failure to thrive, dementia, altered mental status, abnormalities of gait and mobility, and weakness, was identified as high risk for falls. Despite this, the facility did not adequately document or investigate the circumstances surrounding the resident's unwitnessed fall, which resulted in a head injury requiring hospital treatment and staples. Interviews with facility staff, including the Director of Nursing (DON), revealed that the fall incident report for the resident contained many blanks and did not provide a complete picture of the event. The Licensed Vocational Nurse (LVN) and Certified Nurse Aide (CNA) involved in the incident provided inconsistent accounts of the fall, and the DON acknowledged the need for improvement in documenting and understanding the root cause of such incidents. The Administrator also expressed an expectation for staff to determine and document the root cause of falls, which was not met in this case.
Incorrect Enteral Feeding Formula Administered
Penalty
Summary
The facility failed to administer the correct enteral gastrostomy tube feeding as ordered for a resident with a medical history of gastrostomy status and adult failure to thrive. The resident, who was severely impaired in cognitive skills for daily decision-making, was admitted with a care plan requiring tube feeding due to swallowing problems. The physician's order specified the administration of Nepro 1.8 at 40 ml/hr for 20 hours daily. However, during an observation, it was found that the resident was receiving Jevity 1.2 instead of the prescribed Nepro 1.8. Licensed Vocational Nurse (LVN) #9 confirmed the error upon reviewing the physician orders, and LVN #10 admitted to starting the incorrect formula without verifying it against the order. The Medical Doctor was informed of the error but expressed no immediate concern. The facility's Administrator and Director of Nursing acknowledged the mistake, emphasizing that the staff should have verified the physician's order and the formula before administration.
Failure to Serve Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to ensure that a therapeutic diet was served to a resident as ordered by the physician. The resident, who was admitted with a medical history of Alzheimer's disease and dysphagia, was initially on a mechanically altered diet. A physician's order on the morning of the incident changed the resident's diet to a regular, pureed texture diet. However, during a meal observation, a Certified Nurse Aide (CNA) was seen setting up a mechanical soft meal tray for the resident, indicating that the diet change was not communicated effectively. Interviews revealed that a Licensed Vocational Nurse (LVN) had changed the diet order and communicated it to another LVN, who then passed the information to the Registered Dietician (RD) later in the day. The RD stated that she was not aware of the diet change and had not received any communication from the nursing department. This lack of communication resulted in the resident receiving the incorrect diet, contrary to the physician's order.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during the care of a resident with an indwelling catheter. The Centers for Medicare & Medicaid Services (CMS) issued new guidance effective April 1, 2024, requiring the use of EBP for residents with chronic wounds or indwelling medical devices during high-contact care activities. Despite this, the facility did not adhere to these guidelines during the care of a resident with a history of methicillin-resistant Staphylococcus aureus infection and severe cognitive impairment, who was dependent on staff for toileting hygiene and had an indwelling catheter. During an observation, it was noted that the staff, including a Certified Nurse Aide (CNA) and a Licensed Vocational Nurse (LVN), wore gloves and masks but did not wear gowns while providing catheter care to the resident. Interviews with the staff revealed a lack of awareness and understanding of the new EBP requirements, with some staff believing that gowns were only necessary if the resident had an infection. The Infection Control LVN was unaware of the new EBP guidelines, and the Director of Nursing and Administrator expected staff to wear the appropriate personal protective equipment (PPE) but did not ensure compliance.
Medication Transcription Error Leads to Unnecessary Drug Administration
Penalty
Summary
The facility failed to ensure a resident's drug regimen was free from unnecessary medications when nursing staff inaccurately transcribed a physician's order for milk of magnesia (MOM) onto the medication administration record (MAR). The order specified that MOM should be administered every third day as needed for constipation, but it was incorrectly transcribed and administered daily. This error resulted in the resident receiving seven unnecessary doses of MOM, which had the potential to compromise the resident's health and safety due to overuse. The resident, who was admitted with acute respiratory failure and hypoxia, was always incontinent and did not have constipation according to the Minimum Data Set (MDS) assessment. Despite this, the resident received MOM daily on multiple occasions in October 2023, leading to an unwitnessed fall and feces smeared on the floor near the bathroom on one occasion. The interdisciplinary team (IDT) noted the medication error and took steps to monitor the resident for adverse reactions to MOM. Interviews with licensed vocational nurses (LVNs) and the director of nursing (DON) revealed that the medication error occurred due to incorrect transcription by the admitting nurse. The facility's policy on physician orders, dated August 21, 2020, required a process to verify that all physician orders are complete and accurate, which was not followed in this case. The DON stated that a new system was implemented to review all medications with the floor nurse for accuracy after the incident. The resident's care plan was revised to discontinue MOM and monitor for diarrhea or complications, and physician orders were updated to discontinue all bowel medications and call for any constipation issues.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cupertino
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunny View Manor | 0.4 mi | — | 0 | 0 |
| Health Care Ctr At The Forum At Rancho San Antonio | 1.8 mi | — | 22 | 0 |
| Idylwood Care Center | 2.4 mi | — | 0 | 0 |
| Sunnyvale Post-acute Center | 2.5 mi | — | 3 | 0 |
| Los Altos Post-acute | 2.9 mi | — | 2 | 0 |
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