Deficiency Records for Cupertino Healthcare and Wellness Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Cupertino Healthcare and Wellness Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-09 | 2024-01-29 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-10-07 | 2023-10-27 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-07 | 2023-10-27 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-06 | 2023-09-26 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-09-05 | 2023-09-20 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-07-08 | 2023-08-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-05 | 2023-08-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-06 | 2023-07-04 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-05-16 | 2023-06-12 | Y |
| Provide appropriate foot care. | Health | 2023-05-16 | 2023-06-12 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-05-16 | 2023-06-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-09 | 2023-05-27 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-17 | 2023-05-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-13 | 2023-04-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-21 | 2023-03-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-01 | 2023-02-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-23 | 2023-01-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-13 | 2023-01-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-09 | 2022-12-09 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-11-09 | 2022-12-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-17 | 2022-06-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-16 | 2022-04-01 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-12-24 | 2022-01-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-26 | 2021-09-22 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-07-26 | 2021-09-22 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-07-26 | 2021-09-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-26 | 2021-09-22 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-07-26 | 2021-09-22 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-07-26 | 2021-09-22 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-07-26 | 2021-09-22 | N |
| Provide activities to meet all resident's needs. | Health | 2021-07-26 | 2021-09-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-26 | 2021-09-22 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-07-26 | 2021-09-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-26 | 2021-09-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-26 | 2021-09-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-26 | 2021-09-22 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-07-26 | 2021-09-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-07-26 | 2021-09-22 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-07-26 | 2021-09-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-26 | 2021-09-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-26 | 2021-09-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-07-26 | 2021-09-22 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-07-26 | 2021-09-22 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-07-26 | 2021-09-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-26 | 2021-09-22 | N |
| Dispose of garbage and refuse properly. | Health | 2021-07-26 | 2021-09-22 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-07-26 | 2021-09-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-26 | 2021-09-22 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-07-26 | 2021-09-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-07-26 | 2021-09-22 | N |
| Keep all essential equipment working safely. | Health | 2021-07-26 | 2021-09-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-26 | 2021-09-22 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-07-26 | 2021-09-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-26 | 2021-09-22 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Use approved construction type or materials. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-07-28 | 2021-08-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-30 | 2021-07-29 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-02 | 2021-07-01 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-02 | 2021-07-01 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-06-02 | 2021-07-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-02 | 2021-07-01 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-11 | 2019-05-13 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-04-11 | 2019-05-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-04-11 | 2019-05-13 | N |
| Provide activities to meet all resident's needs. | Health | 2019-04-11 | 2019-05-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-11 | 2019-05-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-11 | 2019-05-13 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-04-11 | 2019-05-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-11 | 2019-05-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-11 | 2019-05-13 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-04-11 | 2019-05-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-04-11 | 2019-05-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-11 | 2019-05-13 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-04-11 | 2019-05-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-04-11 | 2019-05-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-11 | 2019-05-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-11 | 2019-05-13 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-05-02 | 2018-05-23 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2018-05-02 | 2018-05-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-02 | 2018-05-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-05-02 | 2018-05-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-05-02 | 2018-05-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-05-02 | 2018-05-23 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-05-02 | 2018-05-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-02 | 2018-05-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-05-02 | 2018-05-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-03-16 | 2018-04-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-16 | 2018-04-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-03-16 | 2018-04-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-03-16 | 2018-04-15 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-03-16 | 2018-04-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-16 | 2018-04-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-03-16 | 2018-04-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-03-16 | 2018-04-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-03-16 | 2018-04-15 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-03-16 | 2018-04-15 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-03-16 | 2018-04-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-03-16 | 2018-04-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-03-16 | 2018-04-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-16 | 2018-04-15 | N |
