Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Vi At Palo Alto during CMS and state inspections, most recent first.
Kitchen staff did not use proper technique when checking sanitizer concentration for food contact surface cleaning. An observation showed a KS dipping a Hydrion QT-40 test strip into the sanitizer solution and removing it immediately instead of immersing it for the required 10 seconds. The RD confirmed the manufacturer’s instructions and acknowledged the correct immersion time.
Care plans for two residents were not kept consistent with current orders and directives. One resident's care plan listed Full Code even though the physician order showed DNR/DNI, and another resident's care plan also listed Full Code despite a DNR/DNI POLST and physician order. For the second resident, the care plan did not address self-administration of medication even though anti-fungal powder was observed at the bedside and the resident said she used it; the DON stated the resident had not been assessed for self-administration and had no related order or care plan.
Failure to act on a consultant pharmacist’s medication regimen review recommendation involved a resident with BPH whose Tamsulosin order remained at 0.4 mg BID instead of the recommended 0.8 mg once daily after the evening meal. The DON said the physician had been notified, but the chart lacked documentation of physician notification or the physician’s response, and the CP confirmed the recommendation was not carried out.
An insulin pen was found opened on a medication cart without a visible resident-specific label. The RN confirmed the pen should have been labeled, and the DON stated the resident label was only on the box from the pharmacy while the individual pen was placed in a labeled bag for repeated use. The facility's medication management policy required resident medications to be labeled with identifying information.
The facility failed to ensure infection control practices were followed when a shared glucometer was returned to the med cart drawer after use on a resident without being disinfected. An LVN stated she was supposed to use Sani-Cloth wipes to sanitize the glucometer after each resident but forgot. The IP stated staff should sanitize the glucometer before and after use with a 2-minute wet dwell time, and the facility policy requires disinfection after each use.
The facility failed to follow its restraint protocol for nine residents using bed rails and canes. Several residents lacked necessary physician orders, informed consent, and care plans, as confirmed by the DON. These omissions potentially compromised residents' rights to informed care decisions.
The facility failed to store food according to professional standards, with opened and undated items found in the pantry freezer and dry storage area. An opened container of mango sorbet and a bag of French lentils were undated, and four bags of peanuts lacked expiration dates. These issues posed a risk of food contamination for all residents receiving food from the kitchen.
The facility failed to protect residents' PHI when staff left laptops open and unattended in hallways, displaying sensitive information. On two occasions, CNAs left laptops open while attending to call lights, resulting in resident information being visible. The DON confirmed that facility policy requires laptops to be locked when unattended.
The facility failed to maintain accurate records for controlled drugs, with discrepancies found between the CDR and MAR for two residents. The DON confirmed missing documentation, acknowledging the requirement for controlled substances to be recorded in both records, as per facility policy.
A survey found a medication error rate of 7.59% in a LTC facility, exceeding the acceptable 5% threshold. Errors included a RN not waiting the required 5 minutes between administering different eye drops to a resident, and a LVN failing to prime a Novolog pen injector before administering insulin to another resident. These actions led to medications not being given as prescribed.
The facility failed to follow infection control practices, including not disinfecting a glucometer after use, inadequate scrubbing of a PICC line hub, and improper glove use and hand hygiene when handling medicated patches. These actions were observed among nursing staff, contrary to facility policies.
A resident with multiple diagnoses and a history of falling was not assessed by physical therapy upon admission due to payer source verification delays. The resident fell, sustained multiple injuries, and subsequently passed away. Facility policies for fall prevention and admission protocols were not adequately followed.
Improper Sanitizer Test Strip Use in Kitchen
Penalty
Summary
Kitchen Staff F did not use proper technique when testing the sanitizer concentration for cleaning food contact surfaces. During a kitchen observation, KS F was seen checking the sanitizer bucket and dipped the sanitizer test strip into the solution, then immediately removed it without allowing the strip to remain in the solution for the required contact time. The Hydrion QT-40 sanitizer test strip instructions stated to immerse the strip for 10 seconds. During an interview and concurrent record review, the Registered Dietitian confirmed that the manufacturer’s instructions require a 10-second immersion time and stated that staff should immerse the sanitizer test strip in the solution for 10 seconds.
Care plans did not match code status orders and omitted self-administration details
Penalty
Summary
The facility failed to develop and revise comprehensive care plans within 7 days of the comprehensive assessment for two sampled residents. For Resident 30, the physician order report showed a DNR/DNI code status, but the care plan dated [DATE] listed the resident as Full Code. During a concurrent interview and record review on [DATE] at 4:00 p.m., the DON confirmed the care plan should have been revised to reflect the physician's DNR/DNI order and acknowledged that it was not revised. Resident 7 was admitted with multiple diagnoses including central cord syndrome at the C4 level, type 2 diabetes mellitus with diabetic neuropathy, long term insulin use, chronic kidney disease, hypertension, glaucoma, rosacea, and long term antibiotic use. The quarterly MDS assessment showed a BIMS score of 15, indicating the resident was cognitively intact. The physician order report listed code status as DNR/DNI, and the POLST dated and signed by the resident indicated Do Not Attempt Resuscitation/DNR (Allow Natural Death), but the care plan dated [DATE] stated the resident's code status was Full Code. For Resident 7, the care plan also did not address self-administration of medication. During observation on [DATE] at 11:27 a.m., one opened and one unopened container of anti-fungal powder were seen on the over-bed table in the resident's room, and the resident stated she used the powder on an irritated area on her abdomen during her stay. The LVN confirmed the containers were at the bedside and stated she did not know they were there or whether they should be in the room. The DON later stated the resident had not been assessed for self-administration of medication and did not have an order or care plan for self-administration of any medication.
Failure to Document and Act on Pharmacist Medication Review Recommendation
Penalty
Summary
The facility failed to act on the consultant pharmacist’s medication regimen review recommendation for one sampled resident with benign prostatic hyperplasia. The resident’s physician orders showed Tamsulosin 0.4 mg, one capsule by mouth twice a day for BPH, while the admission medication regimen review dated 12/26/25 recommended changing the order to Tamsulosin 0.8 mg once daily, given 30 minutes after the evening meal, with the capsules not to be crushed, chewed, or opened. During a concurrent interview and record review, the DON stated the physician had been notified, but the resident’s medical record did not contain documentation of physician notification or the physician’s response to the pharmacist’s recommendation. The DON acknowledged that the physician’s response and rationale, if the physician agreed or disagreed, should be documented in the medical record. The consultant pharmacist stated she completed monthly drug regimen reviews and confirmed that the Tamsulosin recommendation was not carried out. The facility policy required the pharmacist to report irregularities and the physician to document review, actions taken, and rationale if no medication change was made.
Unlabeled Insulin Pen on Medication Cart
Penalty
Summary
The facility failed to ensure proper medication storage and labeling when an insulin pen was found opened on Medication Cart #3 without a visible resident-specific label. During inspection of the cart with the RN, the insulin pen was identified as lacking the resident's name, and the RN confirmed it should have been labeled. The insulin pen was described as a pre-filled pen containing insulin used to lower blood sugar. During an interview, the DON confirmed the insulin pen did not have a resident-specific label. The DON stated that the resident-specific label was placed only on the box of insulin pens when delivered from the pharmacy and stored in the medication room refrigerator, and that one pen was then removed, placed in a cellophane bag labeled with the resident's name, and left in the medication cart for multiple administrations. The report also cited the facility's Medication Management Protocol, which required resident medications to be labeled with the resident's name and other identifying information, and stated that packages with incomplete or illegible labels were to be returned to the pharmacy.
Failure to Disinfect Shared Glucometer After Use
Penalty
Summary
The facility failed to ensure infection control practices were implemented when a shared glucometer was returned to the medication cart drawer after use on one resident without being disinfected. During a medication pass observation, an LVN was seen obtaining a blood sugar reading for Resident 1 and then placing the glucometer back in the cart drawer without sanitizing it. When interviewed, the LVN stated she was supposed to use Sani-Cloth wipes to disinfect the glucometer to prevent the spread of infection between residents and said it is usually sanitized after every resident but she forgot. The Infection Preventionist later stated nurses should sanitize the glucometer before and after use with Sani-Cloth wipes and explained the disinfection process requires a two-minute wet dwell time. The facility policy titled Glucometer Quality Control Testing and Cleaning states the glucometer and fingerstick device are to be disinfected after each use and kept visibly wet for a full 2 minutes.
Failure to Follow Restraint Protocol for Bed Rails and Canes
Penalty
Summary
The facility failed to adhere to its restraint protocol regarding the use of side rails and bed canes for nine residents. For Resident 1, there was no physician order, side rail assessment, consent, or care plan documented for the use of side rails. The Director of Nursing (DON) confirmed these omissions during a record review, acknowledging that these steps should have been completed prior to the installation of the side rails. For Residents 243, 246, and 191, the facility did not have physician orders or care plans for the use of bed canes. The DON confirmed the absence of these critical documents during interviews and record reviews, emphasizing the necessity of having a physician order and care plan in place for the use of bed canes. These residents were observed with bed canes in use without the required documentation. Additionally, Residents 12, 22, 33, 32, and 26 had various documentation deficiencies related to the use of bed canes. While some had care plans in place, they lacked either physician orders or informed consent. The DON confirmed these deficiencies, noting that informed consent and physician orders are essential components of the facility's restraint protocol. These lapses in documentation and protocol adherence potentially compromised the residents' rights to be fully informed and involved in decisions regarding their care.
Improper Food Storage Practices in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety by improperly storing food items in the kitchen. During an initial kitchen tour, an opened and undated container of mango sorbet was found in the pantry freezer. The Executive Chef confirmed that the sorbet was opened and not dated, acknowledging that all items should have been dated when opened. The Executive Chef stated that the mango sorbet must be discarded due to this oversight. Further inspection of the main kitchen dry storage area revealed additional issues. An opened and undated bag of French lentils was found, which the Executive Chef confirmed should have been dated when opened. Additionally, four unopened bags of chopped peanuts were found without expiration dates, as they had been removed from their original box, which contained the expiration date. The Executive Chef stated that these bags of peanuts must be discarded since their expiration date was unknown. These failures had the potential to cause food contamination and food-borne illness to all 37 residents who received their food from the kitchen.
Failure to Protect Resident Information
Penalty
Summary
The facility failed to protect the confidentiality of residents' protected health information (PHI) when staff members left computer screens open and unattended in the hallways of resident care areas. On two separate occasions, laptops displaying sensitive resident information were left unattended on rolling carts outside residents' rooms. The first incident occurred on August 19, 2024, when a certified nursing assistant (CNA A) left a laptop open while attending to a call light, resulting in multiple residents' information being visible. CNA A acknowledged the mistake, stating that the screen should not have been left open and visible to visitors and residents. A similar incident occurred on August 22, 2024, when another certified nursing assistant (CNA B) left a laptop open and unattended, displaying multiple residents' pictures and information. CNA B admitted to stepping away from the laptop to answer a resident's call light and acknowledged that the laptop should have been closed to prevent public visibility of resident information. During an interview, the Director of Nursing (DON) confirmed that the facility's policy required laptops to be locked when unattended to protect patient information. The facility's HIPAA Security policy, revised in June 2011, mandates that electronic protected health information (ePHI) be safeguarded, and employees are required to log off immediately when leaving a workstation.
Discrepancies in Controlled Drug Records
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services by not maintaining accurate records for controlled drugs, specifically oxycodone, for two residents. For Resident 140, there were discrepancies between the controlled drug record (CDR) and the medication administration record (MAR), with instances on 8/19/24 and 8/20/24 where the medication was noted in the CDR but not documented as administered in the MAR. Similarly, for Resident 26, there was an instance on 8/17/24 where the medication was recorded in the CDR but not in the MAR. During the survey, the director of nursing (DON) confirmed the missing documentation for both residents and acknowledged that administration of controlled substances must be recorded in both the CDR and MAR. The facility's policy, last revised in October 2023, requires controlled substances to be signed off in both records. The discrepancies indicate a failure in maintaining accountability for controlled medications, which could potentially lead to misuse or diversion.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 7.59% during a survey, exceeding the acceptable threshold of 5%. This was due to two medication errors observed during administration. In the first instance, a registered nurse (RN) administered Timolol eye drops to a resident and failed to wait the required 5 minutes before administering Simbrinza eye drops, as per the physician's order and facility policy. The RN acknowledged the mistake during an interview, and the Director of Nursing confirmed the expectation to wait between administering different eye drops. In the second instance, a licensed vocational nurse (LVN) administered 3 units of Novolog insulin to another resident without priming the pen injector needle with 2 units, as required by the physician's order and standard administration guidelines. The LVN admitted to not knowing about the priming requirement when questioned. These errors resulted in the residents not receiving their medications as prescribed, potentially affecting the therapeutic outcomes.
Infection Control Deficiencies in Nursing Practices
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for two sampled residents. A Licensed Vocational Nurse (LVN E) did not disinfect a glucometer after using it to test a resident's blood sugar. This was observed during an interview with LVN E, who acknowledged the oversight. The facility's policy requires the glucometer to be disinfected after each use, but this was not followed. Additionally, a Registered Nurse (RN C) did not adequately scrub the hub of a peripherally-inserted central catheter (PICC) line for the required 15 seconds before flushing it with normal saline and connecting intravenous drug tubing. RN C admitted to scrubbing for less than 10 seconds, contrary to the guidelines. Another Registered Nurse (RN D) failed to wear gloves or perform hand hygiene when removing and applying a medicated patch on a resident's chest. RN D stated that gloves were not used because the patch would stick to them, which is against the facility's policy that mandates glove use and hand hygiene during such procedures.
Failure to Provide Adequate Assessment and Supervision
Penalty
Summary
The facility failed to provide adequate assessment and supervision to prevent an accident for a resident when physical therapy did not follow physician's orders to assess the resident's functional ability level upon admission and develop a resident-centered plan of care. This resulted in the resident's fall, head injuries, multiple fractures, and subsequent death. The resident was admitted with multiple diagnoses, including dementia, congestive heart failure, atrial fibrillation, osteoporosis, long-term use of anticoagulant, urinary incontinence, chronic kidney disease, and a history of falling. Despite these conditions, the necessary physical therapy assessment was not conducted upon admission due to the verification of the resident's payer source, which delayed the evaluation process. On the day of the fall, the assigned CNA assisted the resident in the morning, helped her get out of bed, and placed her in a wheelchair next to the bed. The CNA then left the room, and upon returning, found the resident had fallen in the bathroom with her walker by her side. The resident required extensive assistance for transfers, and no staff was aware that the resident was able to stand up and walk prior to the fall. The resident was transferred to the hospital with multiple injuries, including a subarachnoid hemorrhage, rib fractures, and a displaced fracture in the upper arm. The resident returned to the facility on hospice care and subsequently passed away. Interviews with facility staff revealed that physical therapy should have assessed the resident's functional level upon admission, but this was delayed due to the verification of the resident's payer source. The facility's policies and procedures for fall prevention and Medicare/Managed Care admission protocol were not adequately followed, leading to the resident's fall and subsequent injuries. The resident's death certificate indicated the immediate cause of death was multiple blunt force injuries due to the fall.
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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) |
|---|---|---|---|---|
| Atherton Park Post-acute | 1 mi | ★★★★★ | 3 | 0 |
| Palo Alto Post-acute | 1.1 mi | ★★★★★ | 0 | 0 |
| Webster House | 1.3 mi | ★★★★★ | 0 | 0 |
| Devonshire Oaks Nursing Center | 4.2 mi | ★★★★★ | 0 | 0 |
| The Terraces At Los Altos Health Facility | 4.7 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.