Sunnyvale, CA

Sunnyvale Gardens Post Acute

3-star overall rating with 2-star inspections with $43,176 in total fines with 18 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle

1150 Tilton Drive, Sunnyvale, CA

(408) 735-7200

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

140

Certified beds

Average residents

134

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Pacs Group

Operator or chain grouping

Approved since

1991-01-03

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.58

Registered nurse staffing

LPN hours / resident day

0.94

Licensed practical nurse staffing

Aide hours / resident day

2.35

Nurse aide staffing

Weekend hours

3.63

Weekend nurse staffing

RN turnover

48%

Annual RN turnover

Total nurse turnover

55%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 2.5
2.3
0.2 pts worse
1.9
0.6 pts worse
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 1.5
1.6
0.1 pts better
1.8
0.3 pts better
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 100.0%
98.5%
1.5 pts better
93.4%
6.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100.0%
98.2%
1.8 pts better
95.5%
4.5 pts better
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 0.5%
1.6%
1.1 pts better
3.3%
2.8 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 3.4%
6.8%
3.4 pts better
11.4%
8 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 0.6%
4.1%
3.5 pts better
5.4%
4.8 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 7.8%
13.7%
5.9 pts better
19.6%
11.8 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 5.8%
14.2%
8.4 pts better
16.7%
10.9 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained 0.0%
0.4%
0.4 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened 3.2%
11.0%
7.8 pts better
16.3%
13.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 4.3%
10.7%
6.4 pts better
14.9%
10.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
1.0%
1 pts better
1.0%
1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 0.0%
1.2%
1.2 pts better
1.7%
1.7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 11.7%
10.9%
0.8 pts worse
19.8%
8.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 1.4%
4.7%
3.3 pts better
5.1%
3.7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 100.0%
94.0%
6 pts better
81.7%
18.3 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 8.3%
11.2%
2.9 pts better
12.0%
3.7 pts better
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 0.2%
1.5%
1.3 pts better
1.6%
1.4 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 100.0%
93.2%
6.8 pts better
79.7%
20.3 pts better
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 20.4%
23.2%
2.8 pts better
23.9%
3.5 pts better
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-18 · Fire 2024-11-18

19 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

11 fire-safety deficiencies

Top issue: Emergency Preparedness (7 deficiencies)

Cycle 2 Health 2022-11-18 · Fire 2022-11-18

24 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2020-02-28 · Fire 2020-02-28

14 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-11-18

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2024-12-06

F · Potential for more than minimal harm 2024-11-18

E18 · Emergency Preparedness Deficiencies

Fire Safety

Establish procedures for tracking staff and patients during an emergency.

Corrected 2024-12-06

F · Potential for more than minimal harm 2024-11-18

E22 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for sheltering.

Corrected 2024-12-06

F · Potential for more than minimal harm 2024-11-18

E23 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for medical documentation.

Corrected 2024-12-06

F · Potential for more than minimal harm 2024-11-18

E24 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for volunteers.

Corrected 2024-12-06

F · Potential for more than minimal harm 2024-11-18

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-12-06

F · Potential for more than minimal harm 2024-11-18

E9 · Emergency Preparedness Deficiencies

Fire Safety

Include a process for Emergency Preparedness collaboration.

Corrected 2024-12-06

F · Potential for more than minimal harm 2024-11-18

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-12-06

F · Potential for more than minimal harm 2024-11-18

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-18

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-18

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2024-12-06

E · Potential for more than minimal harm 2022-11-18

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2022-12-08

E · Potential for more than minimal harm 2022-11-18

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-12-08

D · Potential for more than minimal harm 2022-11-18

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2022-12-08

D · Potential for more than minimal harm 2022-11-18

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-12-08

D · Potential for more than minimal harm 2022-11-18

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2022-12-08

D · Potential for more than minimal harm 2022-11-18

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-12-08

E · Potential for more than minimal harm 2020-02-28

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2020-08-28

D · Potential for more than minimal harm 2020-02-28

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2020-08-28

D · Potential for more than minimal harm 2020-02-28

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2020-08-28

D · Potential for more than minimal harm 2020-02-28

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2020-08-28

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-03-19

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-04-04

K · Immediate jeopardy 2024-11-27

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-12-16

F · Potential for more than minimal harm 2024-11-18

F802 · Nutrition and Dietary Deficiencies

Health

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Corrected 2024-12-14

E · Potential for more than minimal harm 2024-11-18

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-12-14

E · Potential for more than minimal harm 2024-11-18

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-12-14

E · Potential for more than minimal harm 2024-11-18

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-12-14

E · Potential for more than minimal harm 2024-11-18

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-12-14

E · Potential for more than minimal harm 2024-11-18

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-12-14

E · Potential for more than minimal harm 2024-11-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-18

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-18

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-18

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-18

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-18

F700 · Quality of Life and Care Deficiencies

Health

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-18

F726 · Nursing and Physician Services Deficiencies

Health

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.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-18

F745 · Quality of Life and Care Deficiencies

Health

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-18

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-18

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-18

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-18

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2024-12-14

G · Actual harm 2024-08-15

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-09-25

D · Potential for more than minimal harm 2024-08-15

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2024-09-25

D · Potential for more than minimal harm 2024-08-15

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-09-25

E · Potential for more than minimal harm 2024-06-13

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-07-05

D · Potential for more than minimal harm 2023-03-13

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-03-31

D · Potential for more than minimal harm 2023-03-07

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-03-24

D · Potential for more than minimal harm 2023-03-07

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2023-03-24

F · Potential for more than minimal harm 2022-11-18

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2022-12-16

E · Potential for more than minimal harm 2022-11-18

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2022-12-16

E · Potential for more than minimal harm 2022-11-18

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2022-12-16

E · Potential for more than minimal harm 2022-11-18

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2022-12-16

E · Potential for more than minimal harm 2022-11-18

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2022-12-16

E · Potential for more than minimal harm 2022-11-18

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-12-16

E · Potential for more than minimal harm 2022-11-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-18

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-18

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-18

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-18

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-18

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-18

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-18

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-18

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-18

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-18

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-18

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-18

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-12-16

F · Potential for more than minimal harm 2020-02-28

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2020-03-28

E · Potential for more than minimal harm 2020-02-28

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2020-03-28

E · Potential for more than minimal harm 2020-02-28

F802 · Nutrition and Dietary Deficiencies

Health

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Corrected 2020-03-28

D · Potential for more than minimal harm 2020-02-28

F557 · Resident Rights Deficiencies

Health

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Corrected 2020-03-28

D · Potential for more than minimal harm 2020-02-28

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2020-03-28

D · Potential for more than minimal harm 2020-02-28

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2020-03-28

D · Potential for more than minimal harm 2020-02-28

F685 · Quality of Life and Care Deficiencies

Health

Assist a resident in gaining access to vision and hearing services.

Corrected 2020-03-28

D · Potential for more than minimal harm 2020-02-28

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2020-03-28

D · Potential for more than minimal harm 2020-02-28

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2020-03-28

D · Potential for more than minimal harm 2020-02-28

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2020-03-28

D · Potential for more than minimal harm 2020-02-28

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2020-03-28

Penalties and ownership

What sits behind the stars

$43,176 2024-11-18

Fine

Fine · fine $43,176

Fine

$0 2024-06-13

Payment Denial

Payment Denial · denial start 2024-08-31 · 25 days

25 day denial

Ownership

Providence Group Nh, LLC

5% Or Greater Direct Ownership Interest · Organization

100% 168 facilities 2023-06-30
Apt, Frederick

Operational/Managerial Control · Individual

0% 252 facilities 2024-01-01
Daquigan, Maria

Operational/Managerial Control · Individual

0% 1 facilities 2024-03-11
Hancock, Mark

5% Or Greater Indirect Ownership Interest · Individual

0% 253 facilities 2023-03-10
Jamali, Mehran

Operational/Managerial Control · Individual

0% 5 facilities 2024-03-01
Jergensen, Joshua

Operational/Managerial Control · Individual

0% 237 facilities 2024-01-01
Mitchell, John

Operational/Managerial Control · Individual

0% 254 facilities 2024-01-01
Murray, Jason

5% Or Greater Indirect Ownership Interest · Individual

0% 250 facilities 2024-02-01
Pacs Group, Inc.

5% Or Greater Indirect Ownership Interest · Organization

0% 239 facilities 2023-06-30
Pacs Holdings, LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 238 facilities 2023-06-30
Pierce, Robert

Operational/Managerial Control · Individual

0% 4 facilities 2024-06-14
Truist Bank

5% Or Greater Mortgage Interest · Organization

0% 55 facilities 2023-12-07

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