Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palo Alto Post-acute during CMS and state inspections, most recent first.
During meal service, pureed fish and bread were found to be bland, and several hot food items, including regular and pureed options, were served below the required 135°F. The DM and RD confirmed these issues, which were identified through direct observation and staff interviews.
Surveyors found unsanitary cooking pans with discoloration and rust in the kitchen, and observed a dietary aide failing to follow proper hand hygiene and glove use during meal tray preparation. Both issues were acknowledged by dietary staff and had the potential to impact all residents receiving food from the kitchen.
Surveyors observed multiple infection control lapses, including dusty oxygen concentrator filters for two residents and repeated failures by CNAs and an LVN to perform hand hygiene before and after glove use, between resident contacts, and before handling medications or food. These actions did not follow facility policy or standard infection prevention protocols.
Facility staff did not monitor or document side effects for several residents receiving antibiotics, despite physician orders and facility protocols requiring such monitoring. Nursing staff and the DON confirmed that documentation was missing from the MAR and progress notes, and this was found during interviews and record reviews. The facility's antibiotic stewardship policy required monitoring and documentation, but these were not followed for the affected residents.
A CNA was observed standing while feeding a resident, contrary to facility policy requiring staff to be seated when feeding, and acknowledged she could have adjusted the bed or resident's position to comply. This failure did not honor the resident's right to dignity during mealtime.
An infection preventionist left her laptop open and unattended in a hallway with a resident's face sheet, containing personal and medical information, visible on the screen. She walked away to speak with staff in other areas, leaving the information exposed and unprotected.
Two residents received psychotropic medications without proper informed consent or monitoring. One was given a sedative hypnotic for insomnia without documented consent, monitoring, or a care plan addressing the medication. Another had an antipsychotic dose increased without updated consent. Facility policy requiring informed consent and ongoing evaluation was not followed.
Two residents prescribed antipsychotic medications did not have comprehensive, person-centered care plans specific to their medications, as required by facility policy. For one resident, there was no care plan for Aripiprazole and no baseline AIMS assessment was completed. For another, there was no care plan for Perphenazine, despite care plans for other psychotropic medications. These deficiencies were confirmed by the DON during interviews and record reviews.
A resident admitted with a pacemaker did not have required device information—such as implant date, device and lead details, and follow-up schedule—documented in the clinical record, despite facility policy mandating this documentation. The DON confirmed the absence of this information during record review.
Licensed nurses administered Norco, prescribed for severe pain, to a resident on multiple occasions when her pain level was below the physician-ordered threshold. The DON confirmed that pain medication was not given according to the specified pain level, as documented in the MAR.
Two residents using bed rails for mobility assistance did not have their side rail assessments updated as required by facility policy. Despite physician orders and ongoing use of side rails, the assessments were overdue, and the DON confirmed they were not completed on schedule.
A resident received Ferosul and Calcium Citrate at the same time, despite orders and pharmacy policy requiring assessment for drug interactions. The concurrent administration of these medications, which should be separated to avoid decreased iron absorption, was confirmed by the pharmacist consultant and supported by drug reference materials.
A pharmacist consultant's recommendation to include specific administration instructions for alendronate in a resident's medication record was not followed. The resident, who had osteoporosis, did not have the recommended instructions documented in her administration record, and the DON confirmed this omission during a record review.
A resident receiving dabigatran, an anticoagulant, was not monitored for side effects and did not have the medication use addressed in their care plan, contrary to facility policy. The DON confirmed the lack of monitoring and care planning for this medication.
Surveyors observed a 12% medication error rate when three residents did not receive medications as ordered: one did not receive a prescribed calcium/vitamin D tablet, another was given Diroximel Fumarate without food, and a third did not receive a scheduled inhalation treatment. In each instance, medications were not administered per physician orders or manufacturer instructions, as confirmed by the DON.
Surveyors found that medications and biologicals were not stored properly, including a medication refrigerator with ice buildup and a yellowish-brown substance, as well as expired over-the-counter medications and an opened bottle of medication for a discharged resident in the Central Supply Room. The DON confirmed these issues, which were not in line with facility policy requiring proper sanitation and timely removal of outdated medications.
Seventeen bedrooms were found to have less than the required 80 square feet per resident, with measurements showing square footage per resident ranging from 71.37 to 75. Interviews with residents and staff revealed no reported concerns about space or privacy.
Failure to Ensure Palatable and Properly Heated Food Service
Penalty
Summary
The facility failed to ensure that food served to residents was both palatable and maintained at a safe, appetizing temperature. During a test tray observation and tasting, pureed fish and pureed bread were found to be bland and lacking in taste. The dietary manager acknowledged the issue after tasting the foods, and the registered dietitian confirmed that foods should be palatable and not bland. Facility policies require that resident food preferences be satisfied and that food acceptability be routinely monitored by both food service and nursing staff. Additionally, the temperatures of several hot food items, including regular fish, regular vegetables, pureed fish, pureed orzo, and pureed bread, were measured and found to be below the required 135 degrees Fahrenheit at the time of service. Both the dietary manager and the registered dietitian confirmed that hot foods should be served at or above this temperature, as outlined in the facility's policies and procedures for safe food temperatures. These deficiencies were identified during direct observation and interviews with facility staff.
Failure to Maintain Kitchen Sanitation and Hand Hygiene During Food Preparation
Penalty
Summary
Surveyors observed that the facility failed to maintain proper sanitation and food safety standards in the kitchen. During a kitchen tour, five large cooking pans were found with brownish to blackish discolorations and rusty spots. Both the dietary manager and the registered dietitian acknowledged the unsanitary condition of these pans, confirming that such equipment should not be kept or used in the kitchen. Additionally, during tray line preparation, a dietary aide was seen leaving the kitchen while still wearing gloves, then returning and continuing to assist with meal trays without removing the used gloves, washing hands, or donning new gloves. The dietary aide, dietary manager, and registered dietitian all confirmed that proper hand hygiene and glove use were not followed as required by facility policy. These lapses in sanitation and hand hygiene had the potential to affect all 55 residents receiving food from the kitchen.
Infection Control Deficiencies: Hand Hygiene and Equipment Cleaning Lapses
Penalty
Summary
The facility failed to implement proper infection prevention and control measures in several instances involving both staff and equipment. During observations, the filters of two residents' oxygen concentrators were found to be dusty, despite facility policy and manufacturer recommendations requiring weekly cleaning and preventive maintenance. The infection preventionist confirmed that the filters should have been cleaned, but this was not done as required. Multiple staff members did not adhere to hand hygiene protocols. One certified nursing assistant (CNA) was observed leaving a resident's room with gloves on, disposing of trash in the hallway, and then returning to the resident's room to continue care without changing gloves or sanitizing hands. The same CNA also failed to sanitize hands after removing gloves before retrieving supplies. Another CNA removed gloves after repositioning a resident but did not sanitize hands before assisting with the resident's meal or before leaving the room, handling food items and utensils with potentially contaminated hands. A licensed vocational nurse (LVN) was observed administering oral medications to two residents consecutively without performing hand hygiene before or after glove use, or between resident contacts. The LVN acknowledged the lapse in hand hygiene, and the Director of Nursing confirmed that hand hygiene is required between residents during medication administration. Facility policies reviewed support the need for hand hygiene before and after glove use, between resident contacts, and before handling medications.
Failure to Monitor and Document Antibiotic Side Effects
Penalty
Summary
Facility staff failed to monitor and document the side effects of antibiotic therapy for seven out of eleven residents who were receiving antibiotics. These residents had various medical conditions, including tuberculosis, respiratory failure, pneumonia, aortic valve stenosis, osteomyelitis, COPD, post-liver transplant care, and urinary tract infections. Physician orders for antibiotics such as Levofloxacin, Ethambutal, Linezolid, Vancomycin, Ciprofloxacin, Ceftriaxone, Cefdinir, and Bactrim were present in the residents' records. Interviews with nursing staff, including RNs and the Infection Preventionist, confirmed that the facility's protocol required monitoring for side effects such as rash, hives, dizziness, allergic reactions, nausea, vomiting, and changes in cognition during antibiotic therapy. Staff stated that this monitoring should be documented in the Medication Administration Record (MAR) or progress notes. However, record reviews and staff interviews revealed that there was no documentation of such monitoring for the affected residents during their antibiotic courses. The Director of Nursing verified that there was no documentation of antibiotic monitoring in the MAR or progress notes for the residents in question. The facility's policy on antibiotic prescribing practices required protocols for monitoring and documentation as part of its Antibiotic Stewardship Program, but random audits found these requirements were not met for the residents identified.
Failure to Maintain Resident Dignity During Mealtime
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) was observed standing while feeding lunch to a resident in her room, rather than sitting as required by facility policy. During an interview conducted at the time of the observation, the CNA stated she did not feel comfortable sitting to feed the resident because she had to reach, but acknowledged that she could have adjusted the bed level and repositioned the resident to feed her while seated. The facility's policy on promoting and maintaining resident dignity during mealtimes specifies that all staff should be seated, if possible, when feeding residents. This action did not align with the policy and failed to honor the resident's right to dignity during mealtime.
Resident Confidentiality Breach Due to Unattended Laptop
Penalty
Summary
The infection preventionist (IP) failed to protect a resident's right to confidentiality by leaving her laptop open and unattended in the hallway with the resident's face sheet displayed on the screen. The face sheet contained sensitive information, including the resident's name, address, date of birth, emergency contact, medical history, medications, allergies, and insurance details. The IP left the laptop on a stand in the hallway and walked away to the lobby to speak with the maintenance director, then continued to another hallway to talk with other staff, leaving the screen visible and accessible to unauthorized individuals. The IP later confirmed during an interview that she had left the laptop open and unattended, acknowledging that she should have closed it before leaving.
Failure to Obtain Informed Consent and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medication use, as required by policy and regulation. For one resident with depression and schizoaffective disorder, Belsomra was prescribed and administered for insomnia without obtaining informed consent, without monitoring for sleep or side effects, and without a care plan that addressed the medication's use or related interventions. The Director of Nursing confirmed that there was no documentation of informed consent, no monitoring after the medication was started, and the care plan did not include specific interventions related to Belsomra. For another resident with bipolar disorder and schizophrenia, the dose of the antipsychotic medication Perphenazine was increased without obtaining updated informed consent for the new dosage. The DON verified that the consent on file was for a different dose than what was being administered. Facility policy required that residents or their representatives be informed of the benefits, risks, and alternatives prior to initiating or increasing psychotropic medications, and that such information be documented, but this was not followed in these cases.
Failure to Develop and Implement Comprehensive Care Plans for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents who were prescribed antipsychotic medications. For one resident with diagnoses including anxiety disorder, depression, and unspecified mood disorder, there was no care plan specific to the prescribed antipsychotic medication, Aripiprazole. Additionally, required interventions such as a baseline Abnormal Involuntary Movement Scale (AIMS) assessment were not completed, and the care plan did not address the black box warning associated with the medication. The Director of Nursing (DON) confirmed these omissions during record review and interview, and the facility's policy required ongoing evaluation of psychotropic medication effects in accordance with the resident's care plan. For another resident with bipolar disorder and schizophrenia, the facility did not create a care plan specific to the prescribed antipsychotic medication, Perphenazine. Although this resident had care plans for other psychotropic medications, there was no individualized plan addressing Perphenazine, as verified by the DON. The facility's policy stipulated that all psychotropic medications should be included in the comprehensive care plan, with measurable objectives and timeframes to meet the resident's needs. These deficiencies were identified through interviews and medical record reviews, which revealed that the facility's practices did not align with its own policies and procedures regarding the use of psychotropic medications and the development of comprehensive care plans. The lack of specific care plans and failure to implement required monitoring interventions for antipsychotic medications were directly observed and confirmed by facility staff.
Missing Pacemaker Documentation in Resident Record
Penalty
Summary
The facility failed to ensure that a resident admitted with a pacemaker had complete and necessary information about the device documented in the clinical record. Upon review, the resident's admission record and physician order confirmed the presence of a pacemaker, but the clinical record lacked essential details such as the cardiologist's information, implant date, device model and serial number, lead model and serial number, battery longevity, device settings, and scheduled checkup period. During an interview, the DON was unable to locate any pacemaker information in the resident's record, despite facility policy requiring all pacemaker documentation to be included in the resident's chart and permanent record.
Pain Medication Administered Outside Physician-Ordered Parameters
Penalty
Summary
Licensed nurses administered Norco 5-325 mg, a medication prescribed for severe pain (pain level 7-10), to a resident who had been admitted for aftercare following joint replacement surgery. The physician's order specified that Norco should only be given for severe pain, but the medication was administered on multiple occasions when the resident's pain level was documented as less than 7. These administrations occurred on numerous dates throughout the month, as recorded in the resident's Medication Administration Record (MAR). The Director of Nursing (DON) confirmed upon review of the MAR that Norco was given to the resident when her pain level did not meet the threshold specified in the physician's order. The facility's job description for registered nurses requires compliance with professional standards and physician orders when administering medications. The failure to follow the prescribed pain management protocol resulted in the resident receiving pain medication inappropriately.
Failure to Timely Update Bed Rail Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the proper use and timely reassessment of bed rails for two residents who utilized side rails. For one resident with a history of arthropathic psoriasis, the side rail assessment was last updated several months prior to the observation, despite a physician's order for side rails to assist with bed mobility. The DON confirmed that the assessment had not been updated regularly or quarterly as required. Similarly, another resident with a cervical vertebra fracture had an outdated side rail assessment, with the last update occurring months before the observation, even though there was an active physician's order for side rails for bed mobility. The DON acknowledged that this assessment was also not updated according to the facility's schedule. The facility's policy requires that side rail assessments be completed at least quarterly, upon significant change in status, or when there is a change in the type of bed, mattress, or rail. However, both residents' assessments were not updated in accordance with this policy. These lapses were identified through observation, record review, and interviews with the DON, who verified the assessments were overdue. The failure to update side rail assessments as scheduled constituted a deficiency in the facility's adherence to its own procedures for the safe use of bed rails.
Failure to Separate Administration of Iron and Calcium Resulting in Drug Interaction
Penalty
Summary
The facility failed to ensure the effective use of medications for a resident who was prescribed Ferosul (iron supplement) and Calcium Citrate. According to the resident's clinical record, there were physician orders for Ferosul 325 mg every 48 hours at 9 a.m. for anemia, and Calcium Citrate 250 mg every day at 9 a.m. and 5 p.m. As a result, both medications were administered together at 9 a.m. every 48 hours starting from the date the iron supplement was ordered. During an interview, the pharmacist consultant confirmed that Ferosul and Calcium Citrate should be administered at least two hours apart due to a significant drug-drug interaction that decreases iron absorption. Reference to Lexicomp, a nationally recognized drug information resource, indicated that concurrent administration of calcium and ferrous sulfate can decrease iron absorption by an average of 60%. The facility's policy required the pharmacy to assess medication profiles for potential adverse drug interactions at admission and with each new order, but this was not effectively implemented in this case.
Pharmacist's Medication Administration Recommendation Not Implemented
Penalty
Summary
The facility failed to ensure that a pharmacist consultant's recommendation regarding the administration of alendronate for a resident with osteoporosis was implemented. The pharmacist consultant had recommended that the administration record for alendronate include specific instructions: to administer the intact tablet at least 30 minutes before the first food, beverage, or medication of the day with 6 to 8 ounces of plain water, and to ensure the individual does not lie down for at least 30 minutes and until after the first food of the day. Review of the resident's administration record showed that these instructions were not included as recommended. The director of nursing confirmed during an interview that the recommendation was not acted upon, despite facility policy requiring staff to address all medication regimen review recommendations.
Failure to Monitor and Care Plan Anticoagulant Use
Penalty
Summary
A resident was admitted to the facility and had a physician's order for dabigatran etexilate mesylate, an anticoagulant, to be administered twice daily. Review of the resident's clinical record showed there was no documentation that the resident was monitored for side effects associated with the medication, such as abnormal bleeding or bruising, nor was there evidence that the use of the anticoagulant was addressed in the resident's care plan. The facility's policy on anticoagulant therapy required monitoring for adverse drug effects and inclusion of anticoagulant use and monitoring in the care plan. The DON confirmed during interview that these actions were not completed for this resident.
Medication Error Rate Exceeds Acceptable Threshold Due to Missed and Improper Administration
Penalty
Summary
A medication error rate of 12% was identified during a medication pass, with three errors observed out of 25 opportunities involving three residents. One resident did not receive their prescribed Calcium Carbonate with Vitamin D tablet as ordered by the physician because the medication was not available at the time of administration. Another resident received Diroximel Fumarate capsules, a medication for multiple sclerosis, without food, contrary to the physician's order and manufacturer instructions that specify the medication should be administered at least 20 minutes after food intake. The nurse did not verify if the resident had eaten prior to administration. Additionally, a third resident did not receive their prescribed Fluticasone-Salmeterol inhalation for asthma as ordered, as the medication was not available during the scheduled medication pass. In each case, the medications were not administered in accordance with physician orders and manufacturer specifications, as confirmed by concurrent interviews and record reviews with the Director of Nursing. Facility policy requires medications to be administered as ordered by the physician and in accordance with professional standards of practice.
Improper Storage and Expired Medications Found During Inspection
Penalty
Summary
Surveyors observed that medications and biologicals were not stored in accordance with professional standards and the facility's own policies. During an inspection of the medication room, a mini refrigerator was found with significant ice buildup in the freezer compartment, which prevented the freezer door from closing properly and made it difficult to open. Additionally, a yellowish-brown streak was noted on the right shelf bracket inside the refrigerator. The DON confirmed these findings and acknowledged that the refrigerator could be cleaned better. The facility's policy requires medications to be stored in a manner that ensures proper sanitation and environmental control. In a separate inspection of the Central Supply Room, five expired over-the-counter medications and an opened bottle of medication labeled for a discharged resident were found. The DON confirmed the presence of these expired items and the medication belonging to a discharged resident, stating she was unaware of why they were still stored there. Facility policy specifies that discontinued, outdated, or deteriorated medications should be routinely removed and destroyed according to established procedures.
Failure to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to ensure that 17 out of 27 bedrooms met the required minimum of 80 square feet per resident for multiple occupancy rooms, as determined by room measurements. Specific rooms were identified where the square footage per resident ranged from 71.37 to 75 square feet, which is below the regulatory standard. During the survey, both residents and staff were observed and interviewed, and no concerns or complaints were expressed regarding space or privacy affecting the care provided to residents.
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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 Palo Alto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Webster House | 0.5 mi | ★★★★★ | 0 | 0 |
| Vi At Palo Alto | 1.1 mi | ★★★★★ | 7 | 0 |
| Atherton Park Post-acute | 1.8 mi | ★★★★★ | 3 | 0 |
| The Terraces At Los Altos Health Facility | 4.1 mi | ★★★★★ | 0 | 0 |
| Devonshire Oaks Nursing Center | 5.2 mi | ★★★★★ | 0 | 0 |
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