Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Atherton Park Post-acute during CMS and state inspections, most recent first.
The facility failed to ensure an effective infection prevention and control program by not providing required N95 respirator fit testing for two sampled staff members who are expected to use N95s during COVID-19 outbreaks. An LVN reported using N95s stored on-site for COVID-19 situations but stated she had not been fit-tested at the facility and was last fit-tested over three years earlier in school, and the IP confirmed there was no fit-testing record for her. The IP also acknowledged not being fit-tested at the facility, despite stating that staff must use fit-tested N95s when caring for residents with COVID-19 and that improper fit can allow particles to escape or enter. Review of the facility’s policies showed that all staff must wear N95 or higher-level respirators under enhanced respiratory/contact precautions and that employees required to wear NIOSH-approved N95s must participate in the Respiratory Protection Program with initial and annual fit testing, which had not been completed for these staff.
Staff failed to ensure second-floor windows were secured with tamper-proof limiters, allowing them to be opened far wider than the intended 3-4 inches. Several windows lacked any limiting devices, and some existing limiters could be easily removed or allowed excessive opening. The facility had no policy for window security or inspection, and maintenance checks were undocumented and did not include measuring window openings.
A resident with dementia, depression, and hypertension eloped from the facility and was found offsite in a wheelchair. The care plan in place was not individualized or implemented, as required, and interventions such as disguising exits were not applied. The DON confirmed the care plan was not person-centered or applicable to the resident's needs.
The facility failed to maintain a homelike environment for two residents sharing a room with a disruptive resident who frequently yelled and screamed. One resident, under hospice care with severe cognitive impairment, was visibly distressed, while the other, cognitively intact, reported sleep disturbances and requested a room change. Staff confirmed the frequent yelling, but the DON was reluctant to relocate the disruptive resident.
The facility failed to inform and provide written information about advance directives to 13 residents, as evidenced by the lack of documentation in their POLST forms. Interviews with a Social Services Assistant confirmed the absence of detailed discussions and records regarding advance directives, contrary to the facility's policy.
The facility failed to develop comprehensive care plans for residents with specific needs, including hearing difficulties, anticoagulant therapy, suicidal ideation, and depressed mood. A resident with hearing issues had no care plan, while another on Eliquis for DVT had a care plan incorrectly listing Aspirin. A resident with major depressive disorder lacked a care plan for mental health concerns, and another with dementia and depressed mood had no care plan for emotional distress. These deficiencies were acknowledged by facility staff.
The facility failed to adhere to professional food service safety standards due to the poor condition of chopping boards, which had deep scratches and discoloration. This was observed during an interview with a dietary aide, who acknowledged the boards' condition. The deficiency had the potential to cause foodborne illness for 153 residents.
A facility failed to provide an adequate plan for monitoring and intervention for a resident with suicidal ideation. The resident, diagnosed with major depressive disorder, expressed severe depression and thoughts of wanting to die. Despite being cognitively intact, the resident's symptoms were not communicated to the IDT, resulting in a failure to update the care plan for safety, as required by the facility's policy.
A resident with severe cognitive impairment, indicated by a BIMS score of 2, signed an arbitration agreement without understanding it. The resident had diagnoses of cerebral infarction and cognitive communication deficit. Facility staff, including the Administrator and Director of Nursing, confirmed the resident's lack of comprehension and acknowledged the inappropriateness of the situation.
A resident with cognitive impairment and multiple diagnoses was found with unauthorized medications in her possession, including Tylenol Arthritis, which she was self-administering for pain. The facility failed to conduct a self-administration assessment or document a care plan, as required by their policy. The DON was unaware of the medications, and no interdisciplinary team meeting was held to evaluate the resident's ability to safely self-administer medications.
A resident in an LTC facility did not have a signed admission agreement and received opened mail and packages, leading to feelings of disrespect. The resident, with a history of osteoarthritis, anxiety disorder, PTSD, and morbid obesity, expressed concerns about not receiving facility rules and regulations, affecting her mental health. Staff interviews revealed a lack of follow-up on admission agreements and undocumented plans for managing the resident's mail and packages.
A resident with a history of a right femur fracture and other conditions experienced severe pain after her foot was caught in a wheelchair wheel twice. Despite complaints and a hospital diagnosis of a closed fracture, the facility failed to provide adequate pain management or conduct a comprehensive assessment. The resident managed her pain with Tylenol Arthritis on her own, as the facility did not follow its pain management policies.
Failure to Ensure Required N95 Respirator Fit Testing for Staff
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program by not ensuring required N95 respirator fit testing for staff who are expected to use N95s during COVID-19 outbreaks. During an interview, a LVN stated that the facility uses N95 respirators kept in a plastic cabinet drawer when there is a COVID-19 outbreak and confirmed she had not been fit-tested at the facility, noting her last fit test occurred more than three years ago in nursing school. The Infection Preventionist (IP) confirmed there was no respirator fit testing record for this LVN. The IP also acknowledged that she herself had not been fit-tested at the facility, stating her last fit test was three years prior at a hospital where she previously worked. The IP stated that staff must use an N95 respirator that has been fit-tested for them when caring for residents with COVID-19 and that the facility uses enhanced respiratory precautions for residents with COVID-19 infection. The IP further explained that improper fit could allow particles to escape or enter when not properly covered. Review of the facility’s Enhanced Respiratory and Contact Precautions policy indicated that all staff must wear an N95 or higher-level respirator, and the IP stated this policy is used for COVID-19. The DON stated that respirator fit testing is needed to ensure the mask is well-fitted with no room for contamination and that fit testing must be done annually because facial changes can occur. Review of the facility’s Personal Protective Equipment – Face Masks policy, revised 7/2009, showed that employees required to wear a NIOSH-approved N95 respirator for airborne precautions must participate in the facility’s Respiratory Protection Program per OSHA standards, with initial fit testing before first use of the specific model and annual fit testing every 12 months, which had not been done for at least two sampled staff members.
Failure to Secure Second-Floor Windows with Tamper-Proof Limiters
Penalty
Summary
Facility staff failed to ensure that second-floor windows were properly secured to prevent them from opening more than 4 inches, as required to protect confused residents from the risk of jumping out. During an observation with the Administrator, windows in several rooms on the second floor were found without any devices to limit their opening, allowing them to be opened to at least 30 inches. The Administrator confirmed that mechanical limiters should have been in place but were missing. Further interviews revealed that the window limiting devices used were thumb screws, which could be easily removed by staff, residents, or visitors. The Assistant Maintenance Worker (AMW) stated that he checked the windows weekly but did not document these checks, and admitted that he did not measure how wide the windows could be opened during his audits. An audit conducted by the facility found that out of 80 windows, only specific rooms lacked limiters and could be fully opened. Additionally, there was no facility policy regarding the securing and inspection of windows. Further inspection showed that some windows with limiters could still be opened wider than the intended 3 inches, and in one case, a wood screw was used as an improvised limiter, allowing the window to open to 10.25 inches. These findings were confirmed through observation and interviews with facility staff.
Failure to Develop and Implement Person-Centered Elopement Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan for a resident with dementia, depression, and hypertension after the resident eloped from the facility. The resident was found off facility grounds in his wheelchair by two individuals from a nearby church and was returned to the facility. Documentation showed that this was the first time the resident had eloped, and he stated he left because he wanted to go outside due to the warm weather. At the time of observation, the resident was confused and forgetful, with cognitive status varying from intact to moderately impaired according to recent assessments. Review of the care plan revealed that the interventions listed, such as disguising exits and taping floors, were not implemented and were not personalized to the resident's needs. The DON acknowledged that the care plan was not applicable or individualized for this resident. Facility policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables, but this was not done in this case.
Failure to Provide Homelike Environment Due to Disruptive Resident
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for two residents, Resident 12 and Resident 136, who shared a room with Resident 68. Resident 68 repeatedly yelled and screamed, which disturbed the other residents. Resident 136, who was under hospice care and had severe cognitive impairment, was observed to be visibly distressed by the yelling, as she covered her face and shook her head. Resident 12, who was cognitively intact, expressed dissatisfaction with the situation, stating that the yelling disrupted her sleep and that she had requested a room change from the Social Services Assistant but was still waiting for it to be addressed. Interviews with facility staff, including a CNA and an Activity Assistant, confirmed that Resident 68's yelling was a frequent occurrence, both in the room and during group activities. Despite this, the Director of Nursing expressed reluctance to move Resident 68, suggesting that it would merely relocate the problem. The facility's policy on Resident's Rights emphasizes the importance of a dignified existence and the right to a comfortable environment, which was not upheld in this situation.
Failure to Provide Advance Directive Information to Residents
Penalty
Summary
The facility failed to inform and provide written information to residents or their representatives regarding the formulation of advance directives. This deficiency was identified through interviews and record reviews, which revealed that 13 out of 30 sampled residents did not have evidence of being offered or educated about advance directives. Specifically, the Physician Orders for Life-Sustaining Treatment (POLST) forms for several residents, including Residents 17, 21, 29, 31, 39, 46, 67, 68, 93, 94, 136, 139, and 317, lacked documentation indicating that advance directives were discussed or offered. Interviews with the Social Services Assistant (SSA) confirmed the absence of documentation and the lack of detailed discussions about advance directives with these residents. The facility's policy and procedure documents, revised in September 2022, state that residents have the right to formulate an advance directive and should be provided with written information about this right. The policy also requires that nursing staff document any offer to assist with advance directives and the resident's decision to accept or decline assistance. However, the facility did not adhere to these policies, as evidenced by the lack of documentation and the SSA's acknowledgment of not having specific records for advance directives for the affected residents.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in addressing their specific needs. For one resident with hearing difficulties, there was no care plan in place to address this issue, despite the resident's admission of hearing problems and the need for staff to speak closely to be heard. This lack of a care plan was acknowledged by the LVN during a review of the resident's records. Another resident, who was on anticoagulant therapy with Eliquis for deep vein thrombosis, had a care plan that incorrectly listed Aspirin as the medication being used. The Director of Nursing confirmed that the resident had never been on Aspirin and that the care plan was not person-centered, failing to reflect the actual medication prescribed. Additionally, a resident with major depressive disorder and suicidal ideation did not have a care plan addressing these mental health concerns. The psychiatrist's consultation notes were not communicated with the interdisciplinary team, as acknowledged by the Director of Nursing. Similarly, another resident with dementia and a depressed mood had no care plan developed to address their emotional distress, despite observations of flat affect and distressing behavior. The Social Services Assistant and Director of Nursing both acknowledged the absence of a care plan for this resident.
Deficiency in Food Preparation Standards
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety due to the poor condition of chopping boards. During an observation and interview with a dietary aide, three cutting boards were found to have significant deep scratch marks and were discolored with dark brown and black residue. The dietary aide acknowledged the condition of the cutting boards, noting that they were old and stained. According to the 2017 Federal Food Code, food contact surfaces should be smooth, free of imperfections, and clean to sight and touch. This deficiency had the potential to cause foodborne illness for 153 residents who received food from the kitchen.
Failure to Update Care Plan for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide an adequate plan for staff monitoring and intervention for a resident with suicidal ideation. The resident, who was admitted with major depressive disorder, was found to be experiencing severe depression, lack of interest in activities, social withdrawal, and loss of appetite. Despite being cognitively intact, as indicated by a BIMS score of 15, the resident expressed feelings of hopelessness and worthlessness, and reported significant anxiety and thoughts of wanting to die. These symptoms were documented in a psychiatrist's notes, which rated the resident's depression as a 10 on a scale of 1 to 10. The Director of Nursing acknowledged that the psychiatrist's consultation notes, which highlighted the resident's suicidal thoughts, were not communicated to the Interdisciplinary Team (IDT). This lack of communication resulted in the failure to update the resident's care plan for safety, as required by the facility's policy on Behavioral Assessment, Intervention, and Monitoring. The policy mandates that behavioral symptoms be identified and evaluated by the IDT to determine severity, distress, and potential safety risks, with immediate safety strategies implemented if necessary. The facility's failure to adhere to this policy had the potential for resident harm.
Resident Signed Arbitration Agreement Without Understanding
Penalty
Summary
The facility failed to ensure that a resident understood the arbitration agreement signed during admission. The resident, identified as having severe cognitive impairment with a BIMS score of 2, was admitted with diagnoses including cerebral infarction and cognitive communication deficit. Despite these conditions, the resident signed the arbitration agreement without full comprehension of its terms. Interviews with facility staff, including the Administrator, Director of Admission and Marketing, and the Director of Nursing, confirmed that the resident was not cognitively aware and did not comprehend the agreement. The staff acknowledged that it was inappropriate for a resident with such a severe cognitive impairment to sign the arbitration agreement, as the resident was only alert and oriented to self and did not understand what was being signed.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for self-administration of medications, which led to the resident keeping four bottles of medications in her purse without medical orders. The resident, who was admitted with diagnoses including a fracture of the right femur, Type 2 Diabetes, and Peripheral Vascular Disease, was observed in bed with a leg immobilizer and a bandage on her right foot. During an observation, the resident revealed that she was taking Tylenol Arthritis on her own for pain management, as she claimed the facility only provided Oxycodone in the morning. The medications found in her possession included Senna-Time, an unlabeled bottle of Tylenol Arthritis, an empty bottle of Omega 50+ with CoQ10, and Zegerid OTC. The Director of Nursing (DON) was unaware of the resident having medications in her purse and confirmed that there was no self-administration assessment, care plan, or interdisciplinary team (IDT) meeting documented in the resident's chart. The facility's policy on self-administration of medications requires an IDT assessment to determine if it is clinically appropriate and safe for a resident to self-administer medications. The policy also states that any unauthorized medications found at the bedside should be turned over to the nurse in charge. The resident's Brief Interview for Mental Status (BIMS) score indicated cognitive impairment, which further necessitated a thorough assessment before allowing self-administration of medications.
Resident Rights and Mail Handling Deficiency
Penalty
Summary
The facility failed to ensure that a resident was informed of her rights and that her rights were protected. The resident did not have a signed admission agreement, and she received opened mail and packages, which made her feel disrespected. The resident expressed concerns about not receiving her mail and packages, including an incident where a non-alcoholic eggnog powder package was opened and held by the Director of Nursing (DON) due to a misunderstanding about its contents. The resident also reported not receiving the facility's rules and regulations, which contributed to her feeling disrespected and affected her mental health. Interviews with staff revealed that the resident was given the admission packet on two occasions, but there was no follow-up or protocol to ensure the signed agreement was returned. The facility's policy on receiving packages was verbally communicated to the resident, but there was no written policy or documentation of an interdisciplinary team meeting to address the issues. The resident's concerns about her mail and packages were shared in a group chat that included various department heads, but the administrator did not usually read the chat. The resident, who has a history of osteoarthritis, anxiety disorder, PTSD, and morbid obesity, was also described as a hoarder. The facility had a plan to manage her room's cleanliness and her online orders, but these plans were not documented in writing. The resident's mental health was reportedly affected by the situation, and she expressed feeling disrespected and upset by the facility's handling of her mail and packages. The facility's policies on admission agreements and resident rights were not followed, contributing to the deficiency.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident following multiple incidents involving her right leg. The resident, who had a history of a right femur fracture, Type 2 Diabetes, and Peripheral Vascular Disease, experienced severe pain after her right foot was caught in the wheelchair wheel on two separate occasions. Despite the resident's complaints of pain and the incidents being reported to the nursing staff, there was no comprehensive assessment or adequate pain management provided, leading the resident to call 911 due to uncontrolled pain. The resident was admitted to the hospital, where a closed fracture of the distal end of the right femur was diagnosed. Hospital records indicated that the resident was treated non-operatively and was prescribed a pain management regimen including Tylenol, Motrin, and an opiate narcotic. However, upon returning to the facility, the resident reported that she was not receiving the prescribed pain medication and was managing her pain with Tylenol Arthritis on her own. The facility's failure to document daily assessments and address the resident's pain effectively contributed to the resident's suffering. Interviews with CNAs and the Director of Nursing revealed that the resident's pain was known to the staff, yet there was no documented care plan or comprehensive assessment following the incidents. The facility's policies on pain assessment and management, as well as comprehensive assessments, were not followed, resulting in inadequate care for the resident's pain and condition. The lack of a documented care plan and failure to conduct a comprehensive assessment after the significant change in the resident's condition were key factors in the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Menlo Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vi At Palo Alto | 1 mi | ★★★★★ | 7 | 0 |
| Webster House | 1.7 mi | ★★★★★ | 0 | 0 |
| Palo Alto Post-acute | 1.8 mi | ★★★★★ | 0 | 0 |
| Devonshire Oaks Nursing Center | 3.4 mi | ★★★★★ | 0 | 0 |
| The Sequoias | 5.6 mi | ★★★★★ | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.