Health inspection·December 3, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to provide services according to professional standards for one of two sampled residents (Resident 1) when: 1. Licensed vocational nurse A (LVN A) crushed all of Resident 1's morning medications, mixed them with oatmeal, and left them at Resident 1's bedside; and 2. Certified nursing assistant B (CNA B) administered crushed medications, mixed with oatmeal to Resident 1. These failures had the potential to affect Resident 1's care, health, and well-being.Findings:1.Review of Resident 1's clinical record titled, admission Record, dated 9/25/2025, it indicated Resident 1 was admitted to the facility with diagnoses including myocardial infarction (heart attack), paroxysmal atrial fibrillation (a fast, irregular heartbeat that only lasts a few hours or days), chronic systolic heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and hypertension (HTN - high blood pressure).Review of Resident 1's annual minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], it indicated Resident 1 had a brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Further review indicated Resident 1 was dependent on eating.During an interview with licensed vocational nurse C (LVN C) on 9/25/2025 at 10:40 a.m., LVN C confirmed Resident 1 would take his medications whole by mouth and he had no problem in swallowing. LVN C stated Resident 1 never requested his medications to be crushed and he took them whole with a sip of water. LVN C further stated that if a resident requested for the medications to be crushed, he would not crush them, and would rather call the physician first to get an order, may crush medications, and refer the resident to a speech therapist (ST) as needed.During an interview with registered nurse E (RN E) on 9/25/2025 at 11:38 a.m., RN E confirmed a medication error had happened with Resident 1's morning medications on 9/6/2025. RN E further confirmed LVN A crushed all of Resident 1's morning medications and mixed them with Resident 1's oatmeal. RN E stated some medications like the extended release (ER) should not be crushed because they won't work or would not be the same. RN E further stated Resident 1 was aware that his medications were mixed with his oatmeal and complained about his food tasted bad, and he called FM AA.Review of Resident 1's medication administration record (MAR - a record of medications given), month of September 2025, it indicated the following medications were crushed and administered to Resident 1 on 9/6/2025:a. Amiodarone hydrochloride (a medication that prevents and treats an irregular heartbeat) 200 milligram (mg - unit of measurement) tablet;b. Amlodipine Besylate 10 mg tablet (a medication that lowers blood pressure);c. Aspirin enteric coated (EC - a special coating to resist the stomach's acid and not dissolve until it reaches the small intestine81 mg tablet (an over-the-counter medication used to reduce pain, fever, inflammation and act as a blood thinner);d. Atorvastatin calcium 80 mg tablet (a medication used to lower cholesterol and Residents Affected - Few Page 1 of 3 055407 055407 12/03/2025 Cupertino Healthcare & Wellness Center 22590 Voss Avenue Cupertino, CA 95014

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fats in the blood);e. Clospidogrel bisulfate 75 mg tablet (an antiplatelet drug to prevent blood clots);f. Cyanocobalamin 1000 microgram tablet (a vitamin B12 used to treat and prevent vitamin B12 deficiency);g. Dilantin 30 mg, 2 capsules (brand name for the generic drug phenytoin, an anticonvulsant medication used to control and prevent certain types of seizures);h. Donepezil HCl 10 mg tablet (a medication used to treat symptoms of dementia in people with Alzheimer's disease [a disease characterized by a progressive decline in mental abilities]);i. Folic acid 1 mg tablet (a synthetic B vitamin that helps the body make new cells);j. Isosorbide mononitrate extended release (ER or XR - a medication designed to slowly release the active drug into the body over an extended period of time) 60 mg tablet (a medication used to prevent chest pain);k. Multivitamin one tablet;l. Pantoprazole sodium delayed release 40 mg tablet (a prescription medication that reduces the amount of acid produced in the stomach);m. Levetiracetam 750 mg tablet (an anti-seizure medication used to prevent and control various types of seizures);n. Metoprolol tartrate 100 mg tablet (a medication used to treat high blood pressure);o. Phenytoin sodium extended capsule 100 mg (used to treat and prevent various types of seizures);p. Sennosides 8.6 mg tablet (a medication used to treat constipation); andq. Hydralazine HCl 50 mg tablet (used to treat high blood pressure).During a phone interview with Resident 1's family member AA (FM AA) on 9/25/2025 at 11:53 a.m., FM AA stated Resident 1 called her to complain about his oatmeal tasted, awful. FM AA further stated she learned that LVN A crushed Resident 1's medications and mixed them on his oatmeal. FM AA confirmed that LVN A informed her that she asked CNA B to provide the oatmeal with medications to Resident 1. FM AA stated, the CNA should not give the medications to my dad. FM AA further stated that some of Resident 1's medications should not be crushed.Review of Resident 1's clinical record titled, SBAR [Situation, Background, Assessment, Recommendation - an assessment tool used to facilitate prompt and appropriate communication of a problem] Communication Form and Progress Note for RNs [registered nurses]/LPN [licensed practical nurse]/LVNs, dated 9/9/2025, it indicated, Resident 1's scheduled morning medications were crushed on 9/6/2025.During a review of the health information platform titled, Drugs.com, dated 3/5/2025, indicated a warning, Enteric-coated products should not be dissolved.or crushed prior to consumption. Damaging the coating allows the medicine to be dissolved by acid in the stomach.Further review of the health information platform titled, Drugs.com, dated 11/23/2025, indicated, Isosorbide Mononitrate Extended-Release Tablets should not be chewed or crushed and should be swallowed together with a half-glassful of fluid.Review of the Pantoprazole: Package Insert/Prescribing Info (information), dated 11/20/2025, indicated, Swallow pantoprazole sodium delayed-release tablets whole, with or without food in the stomach.2.During an interview with certified nursing assistant D (CNA D) on 9/25/2025 at 11:17 a.m., CNA D stated she was not allowed to feed the resident if the food was mixed with medications because she was not a nurse.During an interview with the director of staff development (DSD) on 9/25/2025 at 1:55 p.m., the DSD confirmed CNA B fed Resident 1 with oatmeal mixed with medications on 9/6/2025. The DSD stated CNA's should not be giving medications to residents because that was not in the scope of CNA's practice.During an interview with CNA B on 9/25/2025 at 2:28 p.m., CNA B confirmed she assisted Resident 1 with breakfast on 9/6/2025. CNA B stated when she was about to assist Resident 1 with his breakfast, when LVN A came into the room, crushed Resident 1's medications, mixed them on Resident 1's oatmeal and LVN A left the room. CNA B confirmed Resident 1 took some of the oatmeal with his medications and spit it out. CNA B stated she should not have given the oatmeal with medications to Resident 1.During an interview with the director of nursing on 9/25/2025 at 3:18 p.m., the DON confirmed LVN A crushed Resident 1's medication on 9/6/2025. The DON stated, LVN A asked Resident 1 if he wanted his medication with food. The DON further stated, LVN A misinterpreted Resident 1, she 055407 Page 2 of 3 055407 12/03/2025 Cupertino Healthcare & Wellness Center 22590 Voss Avenue Cupertino, CA 95014

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few crushed all his medications and mixed them with his food. The DON stated, Unfortunately, the CNA gave the medications mixed with food to Resident 1.During a review of the facility's policy and procedure titled, Medication-Administration, date revised 1/1/2012, indicated, Medications must be given to the resident by the Licensed Nurse preparing the medication.If the resident has difficulty swallowing pills, the Licensed Nurse will notify the physician to discuss the possibility of a different form of the medication i.e. crushed, liquid or suspension. If the medication is to be crushed, a physician order is required.During a review of the lesson plan on one-on-one in-service with CNA B titled, General Inservice, dated 9/8/2025, indicated, C.N.A are not allowed to give medication to residents in nursing home. It is not within c.n.a scope of practice. Further review indicated nurses are responsible for administration of medications to residents. 055407 Page 3 of 3