Palo Alto Post-Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure palatability and temperature of the foods served were maintained when: 1. The pureed (a smooth, thick liquid or paste made by crushing or grinding solid foods using a blender or food processor) fish and pureed bread tasted bland (lacking taste or flavor); and 2. The temperature of the hot foods served were below the desired level. These failures could lead to decreased nutrient intake for the 55 facility residents receiving food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, cooking and kitchen equipment were maintained properly and foods in the kitchen were prepared in accordance with professional standards for food safety when: 1. There were unsanitary cooking and kitchen equipment stored in the kitchen and, 2. Kitchen staff did not perform hand hygiene and sanitation during the tray line preparation. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness (illness resulting from contaminated food) and cross-contaminated food for the 55 residents who received food from the facility kitchen.

Inspectors wrote2a. Review of Resident 53's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 53's physician order, dated 5/25/25, indicated she had an order for oxygen 2-3 liters per minute (LPM) as needed for shortness of breath. During an observation and interview with the infection preventionist (IP) on 5/27/25, at 10:46 a.m., the filter of Resident 53's oxygen concentrator was dusty. The IP confirmed the filter was dusty and stated the filter should be cleansed every week. 2b. Review of Resident 112's admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 112's physician order, dated 5/22/25, indicated he had an order for oxygen 2-3 LPM continuous every shift. During an observation and interview with the IP on 5/27/25, at 10:51 a.m., the filter of Resident 112's oxygen concentrator was dusty. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that facility staff monitored and documented the side effects of antibiotic (ATB, medication that fight bacteria) therapy for seven out of 11 residents (Residents 165, 9, 57, 267, 15, 269, and 212) who were receiving antibiotics. This failure had the potential to result in unrecognized adverse drug reactions or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of 14 residents (8) with respect and dignity when certified nursing assistant A (CNA A) was standing and feeding Resident 8. This failure had the potential to cause feeling of low self-esteem for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident's rights to confidentiality for one of 14 residents (112) when the infection preventionist (IP) left her laptop screen open with Resident 112's face sheet (a document summarizing key patient information, including name, address, date of birth , emergency contact, medical history, medications, allergies, and insurance details) open and unattended on top of the stand in the hallway. This failure had the potential to compromise the resident's privacy and confidentiality.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 14 sampled residents (Resident 39 and Resident 22) were free from unnecessary psychotropic medication (medications that affect brain activities associated with mental processes and behaviors) use when: 1. Resident 39 was administered Belsomra (Suvorexant, a sedative hypnotic medication used to treat insomnia) without informed consent (a process where the resident or their representative is educated about the risks, benefits, and alternatives to a medication before agreeing to its use), monitoring for sleep or side-effects, and a care plan addressing the medication's use. 2. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to develop and implement a comprehensive person-centered plan of care for two out of 14 sampled residents (Residents 48 and 22) when: 1. Resident 48 did not have a comprehensive care plan specific to the medication Aripiprazole (an antipsychotic medication used to treat several mental health conditions) and interventions indicated in the care plan were not followed. 2. Resident 22 did not have a comprehensive care plan specific to the medication Perphenazine (used to treat the symptoms of schizophrenia, a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). These failures put residents at risk for inadequate monitoring of possible adverse effects specific to their antipsychotic medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received the necessary care and services for one of 14 residents (112) when Resident 112 was admitted with a pacemaker (electric activity-generating device used to treat patients with slow heart rates) but there was no information on the pacemaker found in his clinical record. This failure had the potential to negatively affect the resident's health, well-being, and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents receive the pain management according to their pain levels for one of two residents (53) when the licensed nurses administered Norco (used to relieve severe pain) 5-325 milligrams (mg, a metric unit of mass) to Resident 53 when she did not have severe pain. This failure had the potential for Resident 53 to experience unnecessary adverse effects from the pain medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of side rails or bed rails (adjustable rigid bars attached to the side of a bed) for two of 20 residents who used side rails, (Residents 19 and 28), when their side rail assessments (determine the appropriateness and safety of using side rails on a bed for an individual) were not updated in a timely manner. This failure had the potential to place the residents at risk for entrapment (danger for the resident, being caught, trapped or entangled in the gap, space or opening) that may lead to injury or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure the effective use of medications for one of 14 residents (112) when Resident 112 received Ferosul (iron, used for prevention/treatment of iron deficiency) and Calcium Citrate (a medication used to prevent or treat low blood calcium levels) at the same time. This failure had the potential for the residents to not receive the amount of prescribed iron supplements.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacist consultant's recommendation was acted upon for one of 14 residents (115) when Resident 115's administration record on alendronate (used to prevent and treat osteoporosis [thinning of the bone]) did not include the information the pharmacist consultant asked to be included. This failure had the potential for Residents 115 to receive ineffective medication and adverse effects that could negatively impact her health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 6 residents (112) were free from unnecessary medications when Resident 112 received dabigatran etexilate mesylate (a blood thinner to prevent blood clots) but was not monitored for the side effects and not care-planned on the use of the medication. This failure had the potential for Resident 112 to experience unrecognized adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility had a 12% medication error rate when three medication errors out of 25 opportunities were observed during a medication pass for three out of five sampled residents (Residents 44, Resident 2, and Resident 8) when: 1. Resident 44 did not receive Calcium Carbonate with Vitamin D tablet (used to treat conditions caused by low calcium levels such as bone loss) as ordered by the physician. 2. Resident 2 received Diroximel Fumarate capsule (medication used for the treatment of relapsing forms of multiple sclerosis, a disease that causes breakdown of the protective covering of nerves) without food. 3. Resident 8 did not receive Fluticasone-Salmeterol inhalation (used to treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by asthma) as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored appropriately and in good sanitary condition when: 1. Medication refrigerator had ice build up in the freezer and had a streak of yellowish-brown substance on the shelf bracket. 2. Five expired over-the-counter medications, and an opened bottle of medication for a discharged resident were found in the Central Supply Room. These failures put residents at risk for contaminated medications and had the potential for residents to receive outdated and/or ineffective medications which could lead to residents not receiving the full benefit of the medications and negative health outcomes.

Inspectors wroteBased on observation and interview, the facility failed to ensure 17 of 27 bedrooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was stored in accordance with professional standards for food service safety when: 1. There was an unlabeled and undated crate of oranges and apples in the dry storage area of the kitchen; 2. There was a dented can of kidney beans in the dry storage area of the kitchen; 3. There was no internal thermometer in two kitchen freezers; and 4. There were multiple brown substances on the metal racks in the kitchen reach-in refrigerator. These failures had the potential to cause food contamination and spread foodborne illness to all residents who received their food from the kitchen.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure garbage was stored properly when the lid for the outside dumpster was not closed. This failure had the potential to attract insects, rodents, and other pests to the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement comprehensive, person-centered, care plans for four out of seventeen sampled residents, (Residents 217, 29, 47 and 220), when the activity care plans of Residents 217, 29, 47 and 220, were not comprehensive and person-centered. These failures had the potential to result in the residents, not receiving the interventions necessary to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy regarding use of bed rails (also called side rails, metal or plastic bars attached to the bed ranging in size from full to one-half, one quarter, or one-eighth lengths) for seven out of 19 sampled residents (Residents 4, 20, 21, 43, 213, 32 and 47). For Residents 4, 20, 21, 43, 213, 32, and 47, there was no documentation that indicated the facility attempted alternatives prior to installing bed rails. For Residents 20 and 43, there was no documentation that indicated the facility assessed for risk of entrapment (getting caught, trapped, or entangled in the space in or around the bed rail). This failure had the potential to compromise the residents' safety.

Inspectors wrote2. Review of Resident 57's medical record indicated he was admitted on [DATE] and had the diagnosis of acute pancreatitis (a condition where the pancreas becomes inflamed). Review of Resident 57's Order Summary Report indicated he had a physician's order, dated 2/19/24, to administer Osmolite 1.5 (a type of GT formula) via enteral pump (machine that delivers GT formula) and infuse at 70 milliliters per hour (rate of delivery) for 12 hours. During an observation in Resident 57's room on 2/20/24 at 1:01 p.m., there was a metal pole near Resident 57's bed with a bottle of Osmolite 1.5 hanging from the top of the pole. Some of the Osmolite 1.5 had already been administered, as the bottle was not full and the GT administration tubing was already attached to the bottle. The Osmolite 1.5 bottle and the administration tubing were both unlabeled and undated. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure Level 1 Preadmission Screening and Resident Review (PASARR) was accurately completed upon admission for one of 3 sampled residents (Resident 16), who had diagnosis of mental illness and did not also receive a Level II screening (a comprehensive evaluation conducted by the appropriate state-designated authority to determine whether an individual has a mental disorder or an intellectual disability for the appropriate setting for the individual). This failure had the potential to delay the care when diagnoses of mental illness was not included on the PASARR form, leading to the resident not receiving appropriate care and services in the most integrated setting appropriate to their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medication (medication with high potential for abuse and addiction) and safe use of emergency medications when: 1. Random controlled medication use audit for one of seven residents (Resident 43) did not reconcile. The medication was signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR, used to document medications taken by each individual) to indicate they were administered to the resident. The failure resulted in inaccurate accountability and had the potential for misuse or diversion of controlled medications; and 2. One of five emergency kits (e-kit; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. Medication refrigerator temperature was not monitored twice a day; 2. Resident's own medications brought from home were stored in biohazard bag and were not labeled and, 3. Five nasal sprays in medication carts were not labeled. These failures had the potential for residents to receive medications with reduced efficacy, inadequately monitored medications, unlabelled medications and wrong medications and could compromise residents' safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate food preferences for one of three residents (Resident 114). This failure had the potential to result in decrease meal intake, which could compromise the resident's overall health and well-being.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the call light system (system in which the resident presses a button that activates a light in the hallway to alert staff that assistance is needed) was adequately functioning for one of 15 resident bathrooms (Bathroom AA). This failure had the potential to result in residents not receiving necessary care and assistance in a timely manner.

Inspectors wroteBased on observation and interview, the facility failed to ensure 17 of 27 bedrooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive.

Inspectors wroteBased on interview and record review, the facility failed to complete and submit an investigation summary regarding an alleged abuse incident for one of two sampled residents (Resident 1). This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incident and could have compromised the residents' safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards and receive adequate supervision during smoking sessions to prevent accidents for three of five sampled residents (Residents 92, 192, and 193). When: 1. Resident 92 was not assessed for smoking safety upon admission, was not provided adequate supervision during smoking sessions, and the facility did not initiate smoking care plan timely; and, 2. For Residents 192 and 193, the residents had no smoking assessment and smoking related care plans upon admission and facility staff did not provide supervision during the scheduled smoking time. This failure had potential to cause smoking related accidents/harm of these residents

Inspectors wroteBased on interview and record review, the facility failed to act on reports from the pharmacist for two of five residents (Residents 11 and 24) when: 1. For Resident 11, the physician did not document patient-specific rationales describing the reason for gradual dose reductions (GDR, stepwise tapering of a dose to determine if conditions can be managed by a lower dose or if the medication can be discontinued altogether) are clinically contraindicated for the use of quetiapine (antipsychotic medication used to treat mental or mood disorders) and sertraline (medication used to treat depression) and the facility did not act on the pharmacist's Medication Regimen Review (MRR) recommendation to perform an Abnormal Involuntary Movement Scale (AIMS) assessment; and, 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of five residents (Residents 11, 34, and 242) were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behavior) medications. 1. For Resident 11, there was no documented clinical rationale by the physician to extend an as-needed (PRN) Ativan (medication used to treat anxiety) order beyond 14 days, there was no documented evaluation by the physician to renew a PRN Ativan order, and the Abnormal Involuntary Movement Scale (AIMS) assessment was not completed timely; 2. For Resident 34, there was no side effect monitoring and behavior monitoring for the use of citalopram (medication used to treat depression) and nortriptyline (medication used to treat depression); and 3. For Resident 242, there was no side effect monitoring for the use of nortriptyline. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food safety when: 1. Undated food, over used by date food, expired food, and dented cans were found in the freezer and on the shelves in the kitchen; 2. [NAME] F (CK F) used his bare hand to pick up a lid which dropped inside the sliced peach can; and, 3. [NAME] G (CK G) and the dietary manager (DM) did not sanitize the thermometer before checking the temperature of the sliced peach and sugar free lemonade. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness and cross-contaminated food for the 40 residents eating at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were implemented when: 1. The facility stored clean pillows and residents' clothing next to the dirty laundry; 2. Blood pressure stand machine had five medication cups and one Opti foam dressing together with a blood pressure cuff; 3. The dressing of Resident 26's peripherally inserted central catheter (PICC, a long, flexible thin tube that is put into a vein in the upper arm) was not changed weekly; 4. Certified nursing assistant H (CNA H) carried dirty linen in the hallway out of a resident's room; and, 5. Facility staff did not wear full personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) when entering a resident's room who was on COVID-19 quarantine. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 17) had a Minimum Data Set (MDS, an assessment tool) Significant Change in Status Assessment (SCSA) completed when Resident 17 was discharged from hospice care (physical and emotional care for the terminally ill). This failure had the potential to result in Resident 17 not receiving necessary care and treatments.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 12 residents (Resident 20) received necessary and proper care and services when Resident 20's psychological evaluation (used to determine a resident's mental state and guide recommendations for the best treatment) was not done as requested by the physician. These failures had the potential to affect the residents' care, health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications appropriately when the following were observed: 1. Two of three medication carts were left unlocked and unattended; and, 2. For Residents 295, 193, and 24, medications were left at their bedside. These failures had the potential to result in the access of medications by unauthorized personnel or residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure 17 of 27 bedrooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive.