Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 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 Health Care Ctr At The Forum At Rancho San Antonio during CMS and state inspections, most recent first.
A resident with COPD, HTN, hypothyroidism, and other viral infections, who was cognitively intact per BIMS, was admitted without receiving or signing the required Admission Agreement for Skilled Nursing Facilities, which includes resident rights. Record review showed no admission agreement packet in the chart. The Director of Admission and Marketing confirmed there was no signed agreement or documentation of refusal, and the DON confirmed the packet was not provided at admission, despite facility policy requiring a signed admission agreement on file at admission and a copy given to the resident or representative.
A resident with hypertension experienced medication administration errors when the facility failed to adjust the timing of lisinopril as per a new physician's order. The resident received the medication twice in one day due to incorrect scheduling. Additionally, the facility failed to document the resident's refusal of the evening dose, contrary to its policy. The DON and RN confirmed these errors.
The facility failed to document the advance directive status for several residents, leaving sections of their POLST forms incomplete. This included not discussing or assisting with advance directives for some residents and failing to mark the status on the forms. The facility's policy on advance directives was not adhered to, resulting in incomplete records.
Expired OTC medications and suppositories were found in the medication room, including psyllium powder, geri-lanta, milk of magnesia, prochlorperazine, acetaminophen, bisacodyl, and hydrocortisone. The DON confirmed that licensed staff should have checked expiration dates and disposed of expired items weekly, as per facility policy.
The facility failed to comply with food safety standards, as observed during a survey. Metal bowls used for food preparation were improperly stored while still wet, contrary to the FDA Food Code and facility policy. Additionally, outdated and undated food items were found in the kitchen freezer, including yokisaba noodles and prosciutto past their use-by dates, and undated gnocchi packages. The certified dietary manager confirmed these practices were not in compliance with the facility's policies.
The facility failed to implement proper infection control practices, including a Foley catheter tube on the floor for a resident, unchanged nasal cannula tubes for another resident, and staff not performing hand hygiene after glove removal. The facility's infection preventionist and DON confirmed these practices were not acceptable and did not align with the facility's policies.
A resident's dignity and privacy were compromised when their Foley catheter drain bag was left uncovered in a wash basin on the floor. Staff interviews confirmed that the bag should have been covered with a privacy bag, as per the facility's policy on dignity.
A facility failed to provide a resident with timely notice of the ending of Medicare Part A coverage, as required by policy. The notice was given on the last day of coverage, rather than two days prior, which is necessary to allow the resident the opportunity to appeal for continued payment. This was confirmed by the facility administrator.
A resident with dementia and a history of falls had a wanderguard applied after an elopement attempt, but the MDS inaccurately recorded that the device was not used. The DON confirmed the error, noting the responsible staff member was no longer employed. Accurate MDS documentation is crucial for resident care planning.
A facility failed to implement a care plan for a resident at risk of elopement. Despite the resident's severe cognitive impairment and history of attempted elopement, the facility did not monitor or document the resident's wandering behaviors as required by the care plan. The DON confirmed the lack of implementation of these interventions, which are crucial for maintaining the resident's safety.
A resident was given pantoprazole sodium delayed release after breakfast instead of before, as prescribed. The error was observed during a medication administration and confirmed by the resident. The DON acknowledged the mistake, which was against the facility's policy and procedure.
A resident with a history of transient ischemic attack and heart disease was prescribed oxygen at 5 LPM, but observations revealed it was set at 4 LPM. Staff interviews confirmed the error, and the RN adjusted the rate to the correct setting. The facility's policy required adherence to physician's orders, which was not followed.
The facility failed to assess the appropriateness of bed rails for two residents before installation, lacking necessary documentation such as assessments, alternatives, physician orders, and care plans. The DON confirmed these omissions, which contradict the facility's policy requiring specific criteria to be met before bed rail use.
The facility did not post nurse staffing hours in a prominent place accessible to residents and visitors. The staffing information was located in a hallway blocked off due to construction, as observed during a survey and confirmed by the administrator.
A resident with Alzheimer's disease was prescribed quetiapine for behavioral disorders, but the facility failed to monitor target behaviors or use non-pharmacological approaches to minimize medication use. The pharmacy consultant's recommendations for a gradual dose reduction, approved by the MD, were not followed up, leading to unnecessary medication use.
Failure to Provide and Complete Admission Agreement and Resident Rights on Admission
Penalty
Summary
The facility failed to ensure a resident was informed of his rights upon admission by not completing the required Admission Agreement for Skilled Nursing Facilities. The resident, who had diagnoses including COPD, essential hypertension, hypothyroidism, and other viral infections, was admitted on a specified date and had a BIMS score of 15, indicating he was cognitively intact. Review of the resident’s clinical record showed that the admission agreement packet, which includes resident rights, was not present in the medical record. During a concurrent interview and record review, the Director of Admission and Marketing confirmed there was no admission agreement on file for this resident and stated that the resident had not signed the admission agreement, including the section on resident rights, and that it should have been documented if the resident did not sign. The DON also confirmed that the resident was not provided with the admission agreement packet at the time of admission. Review of the facility’s Admission Agreement policy, revised 12/2025, indicated that all residents must have a signed and dated admission agreement on file at the time of admission, that a copy must be provided to the resident or representative, and that the agreement clarifies facility services, accommodations, and the financial obligations and responsibilities of the resident. This policy requirement was not followed for this resident.
Medication Administration Errors and Documentation Failures
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident with hypertension. The resident had a physician's order for lisinopril, a medication used to lower blood pressure, to be administered once daily in the morning. On a specific day, the physician changed the administration time to the evening, but the staff incorrectly scheduled the new time to start on the same day, resulting in the resident receiving the medication twice in one day. The Director of Nursing (DON) and the registered nurse (RN) involved confirmed the error, acknowledging that the new administration time should have started the following day. Additionally, the facility documented that the resident received the evening dose of lisinopril, although the resident had refused it, as she had already taken the medication in the morning. The facility's policy requires documentation of medication refusal, but there was no record of the refusal in the resident's medical record. The DON confirmed the lack of documentation and acknowledged that the refusal should have been recorded according to the facility's policy.
Failure to Document Advance Directive Status
Penalty
Summary
The facility failed to ensure that five residents had proper documentation regarding their advance directive status. For Residents 13, 24, 334, and 336, there was no evidence that the facility discussed or assisted in executing an advance directive, nor was there documentation of a request for a copy of an executed advance directive. Specifically, Resident 13's POLST form had all options for advance directive status left blank, and there was no documentation in the clinical record regarding advance directives. Similarly, Resident 24's POLST form indicated that an advance directive was not available, and there was no documented discussion or assistance provided. Resident 334's POLST form also noted no advance directive, with no evidence of facility engagement on the matter. Resident 336's POLST form was incomplete, with all options left blank. Additionally, Resident 3's POLST form was incomplete, with no checked boxes indicating the status of their advance directive. The admissions staff confirmed that Resident 3's advance directive was not in the system, and none of the checkboxes in section D of the POLST were marked. The facility's policy requires that the existence of an advance directive be determined upon admission and documented in the medical record, with assistance offered if needed. However, this policy was not followed, leading to incomplete documentation and a lack of clarity regarding the residents' advance directive status.
Expired Medications Found in Facility's Medication Room
Penalty
Summary
The facility failed to ensure proper storage of medications in the medication room, as observed during a survey. Expired over-the-counter (OTC) medications, including psyllium powder, geri-lanta, and milk of magnesia, were found in the OTC medication supply cabinet. These medications had expiration dates ranging from May to June 2024. The Director of Nursing (DON) confirmed these findings and acknowledged that licensed nursing staff should have verified expiration dates and removed expired medications weekly. Additionally, expired suppositories were found in the same medication room. These included prochlorperazine, acetaminophen, bisacodyl, and hydrocortisone suppositories, with expiration dates as far back as March 2023. A box of benacalorie nutritional supplement was also expired. The DON confirmed these observations and reiterated that licensed staff should have checked expiration dates and disposed of expired medications and supplements weekly. The facility's policy and procedure for the disposal of expired medications, revised in February 2023, indicated that discontinued or outdated medications should be placed in a designated, secure location for destruction.
Food Safety Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as observed during a survey. The first issue identified was the improper storage of bowls used for food preparation and service. During an observation, several metal bowls were found stacked while still wet, which contradicts the facility's policy and the FDA Food Code that requires equipment and utensils to be air-dried before being stored. The certified dietary manager confirmed the improper practice, acknowledging that the bowls should have been allowed to air dry before stacking. The second issue involved the storage of undated and outdated food items in the facility's kitchen freezer. During a kitchen tour, several food items were found to be past their manufacturer's use-by dates, including a bag of yokisaba noodles and packages of prosciutto. Additionally, packages of gnocchi with spinach were found without any use-by dates, likely due to being removed from their original packaging. The certified dietary manager confirmed these items were beyond their use-by dates or undated and should be discarded, which was not in compliance with the facility's policy requiring all stored foods to be labeled and dated.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices in several instances, which could lead to the spread of infections and cross-contamination among residents. For Resident 332, the tubing of a Foley catheter was observed lying on the floor next to the resident's bed. The licensed vocational nurse (LVN) acknowledged that the tubing should have been placed above the floor to prevent infection. Similarly, for Resident 334, nasal cannula tubes were found on the floor and had not been changed according to the physician's orders. The LVN confirmed that the nasal cannula tubing should have been placed in a bag when not in use and changed weekly. Additionally, during a medication administration observation, an LVN failed to perform hand hygiene after removing gloves, which is a critical step in preventing infection. The LVN admitted to not washing hands after glove removal, which is against the facility's policy. Furthermore, a phlebotomist was observed walking in the hallway with gloves on, which is not in line with standard infection control practices. The phlebotomist acknowledged the mistake and stated that gloves should be removed, and hands should be washed before entering the hallway. The facility's infection preventionist and director of nursing confirmed that these practices were not acceptable and did not align with the facility's policies and procedures. The facility lacked a specific policy covering the placement of nasal cannula and oxygen tubing, which contributed to the oversight. The facility's policies on hand hygiene and glove use were not followed, leading to potential risks of infection spread among residents.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident, identified as Resident 332, by not covering the resident's Foley catheter drain bag. Resident 332 was admitted to the facility with a diagnosis that included a fracture of the superior rim of the left pubis and had a physician's order for a Foley catheter. During an observation, it was noted that the resident's Foley catheter drain bag was left uncovered and placed in a wash basin on the floor next to the resident's bed. Interviews with the licensed vocational nurse, the infection preventionist, and the director of nursing confirmed that the Foley catheter drain bag should have been covered with a privacy bag to maintain the resident's dignity and privacy. The facility's policy and procedure on dignity, revised in February 2021, also indicated that urinary catheter bags should be covered to promote dignity and respect for residents.
Failure to Provide Timely Medicare Coverage Termination Notice
Penalty
Summary
The facility failed to provide timely notice of the ending of Medicare Part A coverage to a resident, which is a requirement to allow the resident the opportunity to appeal for continued payment by Medicare. Specifically, the Skilled Nursing Facility Beneficiary Notification Review (SNF BNR) for the resident indicated that the last day of Medicare Part A Skilled Services coverage was on the same day the notice was signed, which was 5/23/2024. According to the facility's policy, the Notice of Medicare Non-Coverage (NOMNC) should be given no later than two days before the termination of services. However, in this case, the notice was provided on the last day of coverage, not allowing the required 48-hour notice period. This discrepancy was confirmed during an interview with the facility administrator, who acknowledged the failure to adhere to the policy.
Inaccurate MDS Assessment for Resident with Wanderguard
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, identified as Resident 19, which led to a deficiency. Resident 19, who had diagnoses including dementia and a history of falling, required assistance with personal care. An incident occurred where Resident 19 attempted to elope, prompting the physician to order a wanderguard, a device that activates an alarm when a resident attempts to leave a safe area. The family consented to the application of the wanderguard on Resident 19's left wrist. However, the MDS assessment conducted on a later date inaccurately indicated that the wanderguard was not used, despite the device being in place. During an interview and record review, the Director of Nursing (DON) confirmed that Resident 19 was indeed wearing a wanderguard and that the MDS was incorrect. The DON acknowledged that the MDS should have reflected the use of the wanderguard. The staff member responsible for the inaccurate MDS was no longer employed at the facility and unavailable for comment. According to the Resident Assessment Instrument Manual, alarms such as wanderguards should be accurately recorded in the MDS to ensure proper monitoring and care planning for residents.
Failure to Implement Elopement Risk Care Plan
Penalty
Summary
The facility failed to implement the elopement risk care plan for a resident identified as an elopement risk. The resident, who has severe cognitive impairment due to dementia and a history of falling, attempted to elope on a previous occasion. Following this incident, a wanderguard was applied to the resident's wrist as a preventive measure. However, the facility did not follow through with the care plan interventions, which included identifying patterns of wandering, monitoring the resident's location throughout shifts, and documenting wandering behavior. During an interview and record review, the Director of Nursing confirmed that the interventions outlined in the care plan were not implemented. The resident's treatment record lacked documentation of wandering behaviors or exit-seeking episodes, despite the care plan's requirement for such monitoring. The facility's policy on wandering and elopements emphasizes the importance of identifying residents at risk and implementing strategies to maintain their safety, which was not adhered to in this case.
Medication Administration Error for a Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure for medication administration for a resident, identified as Resident 340. The resident was prescribed pantoprazole sodium delayed release 40 mg to be taken every morning before breakfast. However, during a medication administration observation, it was noted that the medication was given after breakfast by a licensed vocational nurse (LVN A). This was confirmed by Resident 340 during an interview, who stated that all medications were administered after breakfast, contrary to the physician's orders. The director of nursing (DON) acknowledged that the medication should have been administered before breakfast, as per the medical doctor's order. The facility's policy and procedure, revised in July 2016, requires nursing staff to review the overall situation for the resident to ensure that any related issues are addressed. This oversight in following the prescribed medication schedule had the potential to affect the health and well-being of Resident 340, who had an intact cognition as indicated by a BIMS score of 14/15.
Failure to Follow Oxygen Administration Orders
Penalty
Summary
The facility failed to adhere to physician's orders for administering oxygen to a resident, identified as Resident 24. The resident was admitted with diagnoses including transient ischemic attack, thrombocytosis, and atherosclerotic heart disease. According to the physician's orders dated 6/23/2024, the resident was to receive oxygen at 5 liters per minute (LPM) via nasal cannula continuously, with the option to increase to 8 LPM if oxygen saturation fell below 90 or if there was increased shortness of breath. However, during observations on 7/15/2024 and 7/17/2024, it was noted that the resident's room air concentrator was set at 4 LPM, which was below the prescribed rate. Interviews with staff, including a licensed vocational nurse and a registered nurse, confirmed the discrepancy in the oxygen rate setting. The registered nurse acknowledged the error and adjusted the oxygen rate to the correct 5 LPM as per the physician's order. The director of nursing also confirmed that the staff should have followed the physician's order to set the oxygen rate at 5 LPM. The facility's policy and procedure for oxygen administration emphasized verifying and following physician's orders, which was not adhered to in this instance.
Failure to Assess Bed Rail Appropriateness
Penalty
Summary
The facility failed to determine the appropriateness of bed rails for two residents before installation, which could potentially lead to harm from improper use. For Resident 17, there was no bed rail assessment, documentation of alternatives used, physician order, or care plan prior to the installation of the bed rails. Similarly, for Resident 81, there was no bed rail assessment, documentation of alternatives used, physician order, or care plan prior to the installation. During an interview, the DON confirmed the absence of these necessary documents for both residents. The facility's policy on bed safety and bed rails, revised in August 2022, prohibits the use of bed rails unless specific criteria are met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to comply with federal regulations by not posting the nurse staffing hours in a prominent place that is readily accessible to residents and visitors. During a survey, it was observed that the posting for the licensed and unlicensed nursing staff's total number and actual hours worked was not visible at the nurses' station. Upon inquiry, the administrator explained that the staffing information was posted in a hallway currently blocked off due to construction and painting activities.
Failure to Monitor and Reduce Unnecessary Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication, specifically quetiapine, due to several oversights. There was no documented evidence of target behavior monitoring for the use of quetiapine, nor were non-pharmacological approaches utilized to minimize the need for this medication. Additionally, the pharmacy consultant's recommendations for a gradual dose reduction of quetiapine were not followed up, despite the medical doctor's approval of these recommendations. The resident in question was admitted with a diagnosis of Alzheimer's disease and was prescribed quetiapine for behavioral disorders. The facility's director of nursing acknowledged the lack of monitoring for target behaviors, the absence of non-pharmacological interventions, and the failure to follow up on the pharmacy consultant's and MD's recommendations. This lack of action resulted in inadequate monitoring and the continued use of unnecessary medication for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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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) |
|---|---|---|---|---|
| Los Altos Post-acute | 1.2 mi | — | 2 | 0 |
| Sunny View Manor | 1.5 mi | — | 0 | 0 |
| Cupertino Healthcare & Wellness Center | 1.8 mi | — | 25 | 0 |
| Idylwood Care Center | 1.9 mi | — | 0 | 0 |
| Sunnyvale Post-acute Center | 1.9 mi | — | 3 | 0 |
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