Inspection visit
Health inspection
11 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0645
PASARR screening for Mental disorders or Intellectual Disabilities
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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).
Residents Affected - Few
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.
Findings:
A review of Resident 16's admission record (face sheet, a document that gives resident's information at a
quick glance) indicated, the resident was admitted to the facility on [DATE], with diagnoses that included
vascular dementia (loss of memory and other mental abilities severe enough to interfere with daily life),
depression (a mental health disorder characterized by persistently depressed mood or loss of interest in
activities, causing significant impairment in daily life), delusional disorders (is a type of psychotic disorder
and its main symptom is the presence of one or more delusions; a delusion is an unshakable belief in
something that's untrue; the belief isn't a part of the person's culture or subculture, and almost everyone
else knows this belief to be false) and schizoaffective disorder (a mental illness that can affect your
thoughts, mood, and behavior).
A review of Resident #16's Preadmission Screening and Resident Review Level I Screening, dated
10/07/23 from acute hospital indicated, Resident #16 did not have a diagnosed mental disorder such as
depression, schizoaffective disorder, delusional, and/or mood disorder.
A review of Resident #16's care plan, initiated 10/12/2021, indicated Resident #16 had a mood problem
related to schizoaffective syndrome such as delusion and paranoid.
A review of Resident #16's Order Summary Report with active orders as of 10/10/2023, revealed an order
dated 02/23/2024 and was clarified, for haloperidol (medication for mental illness) 1 milligram, one tablet by
mouth at bedtime for schizoaffective syndrome.
During a concurrent interview and record review on 2/21/2024 at 3:10 PM, with the social services director
(SSD), SSD reviewed Resident 16's PASARR dated 10/20/23 and confirmed that Resident #16's diagnosis
of vascular dementia, depression, schizoaffective disorder, delusional, and/or mood disorder
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 24
Event ID:
055646
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0645
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
should have been on the resident's PASARR upon admission and it should have been checked for accuracy
by looking over the physician's orders, face sheet and the history and physical. SSD further stated that new
reassessment screening should have been created due to the following diagnosis stated above and that will
be triggered PASARR level 2 screening.
Review of a facility policy titled, Resident Assessment - Coordination with PASARR Program, revised in
10/31/2023, revealed, This facility coordinates assessments with the preadmission screening and resident
review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual
disability, or a related condition receives care and services in the most integrated setting appropriate to
their needs.
Event ID:
Facility ID:
055646
If continuation sheet
Page 2 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings:
1. Review of Resident 217's face sheet (a document that gives resident's information at a quick glance)
indicated, Resident 217 was admitted to the facility on [DATE] with diagnoses including systemic sclerosis
(an autoimmune disorder in which the immune system attacks own body, affecting many systems of the
body) with lung involvement, dysphagia (difficulty swallowing), oropharyngeal phase (swallowing problems
occurring in the mouth and/or throat) and essential primary hypertension (abnormally high blood pressure
that's not the result of a medical condition).
During an observation of Resident 217 on 2/20/24 at 12:50 p.m., Resident 217 was laying in her bed, alert,
calm and verbally responsive.
Review of Resident 217's active physician orders as of 2/21/24 indicated, Resident 217 may participate in
activities, reviewed and approved, when not in conflict with treatment, ordered on 2/2/24.
During the interview with the activity director (AD), on 2/22/24 at 3:39 p.m., AD stated that the activity
assistant (AA), goes to Resident 217's room for room visits and to check on Resident 217, twice per day.
Review of Resident 217's care plans indicated, Resident 217 did not have room visits in the interventions of
her activity care plan and there were no specific activities to be provided during the room visits. Resident
217's activity care plan, was not comprehensive and person-centered, that includes measurable objectives
and timetables to meet the resident's physical, psychosocial and functional needs.
During a concurrent record review of Resident 217's activity care plan and interview with AD, on 2/23/24 at
11:15 a.m., AD verified, Resident 217 did not have room visits in the interventions of her activity care plan
and there were no specific activities to be provided during the room visits. AD further verified, Resident
217's activity care plan, was not comprehensive and person-centered, that includes measurable objectives
and timetables to meet the resident's physical, psychosocial and functional needs. AD then stated that
Resident 217 should have comprehensive, person-centered activity care plan and she will update Resident
217's activity care plan.
During a concurrent record review of Resident 217's activity care plan and interview with the director of
nursing (DON), on 2/23/24 at 2:17 p.m., DON verified, Resident 217 did not have comprehensive,
person-centered activity care plan. DON further verified, Resident 217 should have comprehensive,
person-centered activity care plan.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 3 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
2. Review of Resident 29's face sheet indicated, Resident 29 was readmitted to the facility on [DATE] with
diagnoses including osteomyelitis of vertebra (rare spine infection, causing weakness in it's structure or
pressure on the spinal cord or nerve roots), lumbar region (lower back), Parkinson's disease (disorder of
the central nervous system that affects movement, often including tremors) without dyskinesia
(uncontrolled, involuntary muscle movement) with fluctuations (irregular shifting) and hyperlipidemia (high
levels of fat particles in the blood).
During an observation of Resident 29 on 2/20/24 at 10:38 a.m., Resident 29 was sitting in his wheelchair,
alert, calm and comfortable.
Review of Resident 29's active physician orders as of 2/21/24 indicated, Resident 29 may participate in
activities, reviewed and approved, when not in conflict with treatment plan, ordered on 1/19/24.
During the interview with the activity director (AD), on 2/22/24 at 3:39 p.m., AD stated that they try to do
one-on-one with Resident 29 in the activity room, usually with iPad (a touchscreen tablet computer, smaller
than a typical laptop, made by Apple Incorporated, an American manufacturer of personal computers,
smartphones, tablet computers, computer peripherals and computer software and one of the most
recognizable brands in the world).
Review of Resident 29's care plans indicated, Resident 29 did not have specific activities to be provided
during his one-on-one visits, in the interventions of Resident 29's activity care plan. Resident 29's activity
care plan, was not comprehensive and person-centered, that includes measurable objectives and
timetables to meet the resident's physical, psychosocial and functional needs.
During a concurrent record review of Resident 29's activity care plan and interview with AD, on 2/23/24 at
11:18 a.m., AD verified, Resident 29 did not have specific activities to be provided during his one-on-one
visits, in the interventions of Resident 29's activity care plan. AD further verified, Resident 29's activity care
plan, was not comprehensive and person-centered, that includes measurable objectives and timetables to
meet the resident's physical, psychosocial and functional needs. AD further verified that Resident 29 should
have comprehensive, person-centered activity care plan and she will update Resident 29's activity care
plan.
During a concurrent record review of Resident 29's activity care plan and interview with the DON, on
2/23/24 at 2:20 p.m., DON verified, Resident 29 did not have comprehensive, person-centered activity care
plan. DON further verified, Resident 29 should have comprehensive, person-centered activity care plan.
3. Review of Resident 47's face sheet indicated, Resident 47 was readmitted to the facility on [DATE] with
diagnoses including other displaced fracture (the ends of the bone have come out of alignment) of third
cervical vertebra (one of the seven cervical vertebrae of the neck and the most superior one), subsequent
encounter for fracture (a partial or complete break in the bone) with routine healing, type 2 diabetes mellitus
(adult onset high blood sugar) and unspecified liver cirrhosis (chronic liver damage from a variety of causes
leading to scarring and liver failure).
During an observation of Resident 47 on 2/20/24 at 10:38 a.m., Resident 47 was sitting in his chair, alert,
oriented, calm and comfortable.
Review of Resident 47's active physician orders as of 2/21/24 indicated, Resident 47 may
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 4 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
participate in activities, reviewed and approved, when not in conflict with treatment plan, ordered on
2/15/24.
During the interview with the activity director (AD), on 2/22/24 at 3:57 p.m., AD stated that the activity
assistant (AA), goes to Resident 47's room for room visits and to check on Resident 47, twice per day.
Residents Affected - Some
Review of Resident 47's care plans indicated, Resident 47 did not have room visits in the interventions of
his activity care plan and there were no specific activities to be provided during the room visits. Resident
47's activity care plan, was not comprehensive and person-centered, that includes measurable objectives
and timetables to meet the resident's physical, psychosocial and functional needs.
During a concurrent record review of Resident 47's activity care plan and interview with AD, on 2/23/24 at
11:21 a.m., AD verified, Resident 47 did not have room visits in the interventions of his activity care plan
and there were no specific activities to be provided during the room visits. AD further verified, Resident 47's
activity care plan, was not comprehensive and person-centered, that includes measurable objectives and
timetables to meet the resident's physical, psychosocial and functional needs. AD then stated that Resident
47 should have comprehensive, person-centered activity care plan and she will update Resident 47's
activity care plan.
During a concurrent record review of Resident 47's activity care plan and interview with the DON, on
2/23/24 at 2:23 p.m., DON verified, Resident 47 did not have comprehensive, person-centered activity care
plan. DON further verified, Resident 47 should have comprehensive, person-centered activity care plan.
4. Review of Resident 220's face sheet indicated, Resident 220 was admitted to the facility on [DATE] with
diagnoses including hypo-osmolality (a condition where the levels of electrolytes, proteins and nutrients in
the blood are lower than normal) and hyponatremia (low blood sodium), essential primary hypertension
(abnormally high blood pressure that's not the result of a medical condition) and malignant neoplasm
(cancerous tumor which develops when abnormal cells grow, multiply and spread to other parts of the
body) of unspecified site of unspecified female breast.
During an observation of Resident 220 on 2/20/24 at 11:35 a.m., Resident 220 was laying in her bed, alert,
oriented, calm and comfortable.
Review of Resident 220's active physician orders as of 2/21/24 indicated, Resident 220 may participate in
activities, reviewed and approved, when not in conflict with treatment plan, ordered on 2/5/24.
During the interview with the activity director (AD), on 2/22/24 at 4:02 p.m., AD stated that the activity
assistant (AA), goes to Resident 220's room for room visits and to check on Resident 220, twice per day.
Review of Resident 220's care plans indicated, Resident 220 did not have room visits in the interventions of
her activity care plan and there were no specific activities to be provided during the room visits. Resident
220's activity care plan, was not comprehensive and person-centered, that includes measurable objectives
and timetables to meet the resident's physical, psychosocial and functional needs.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 5 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During a concurrent record review of Resident 220's activity care plan and interview with AD, on 2/23/24 at
11:25 a.m., AD verified, Resident 220 did not have room visits in the interventions of her activity care plan
and there were no specific activities to be provided during the room visits. AD further verified, Resident
220's activity care plan, was not comprehensive and person-centered, that includes measurable objectives
and timetables to meet the resident's physical, psychosocial and functional needs. AD then stated that
Resident 220 should have comprehensive, person-centered activity care plan and she will update Resident
220's activity care plan.
During a concurrent record review of Resident 220's activity care plan and interview with the DON, on
2/23/24 at 2:27 p.m., DON verified, Resident 220 did not have comprehensive, person-centered activity
care plan. DON further verified, Resident 220 should have comprehensive, person-centered activity care
plan.
Review of the facility's policy and procedure titled, Care Plan, Comprehensive, dated 2008 indicated, It is
the policy of this facility to develop, in conjunction with the resident and/or representative, the
Comprehensive Resident Care Plan. The care plan is directed toward achieving and maintaining optimal
status of health, functional ability and quality of life. The care plan is individualized by identified resident
problems, unique characteristics, strengths and individual needs. Each plan should be realistic and have
measurable goals and time frames and responsibility for meeting the specific goals.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 6 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a
resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed
consent; and (4) Correctly install and maintain the bed rail.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings:
1. During an observation on 2/21/24 from 9:41 a.m. to 9:58 a.m., the beds of Residents 4, 20, 21, and 43
were inspected. All of these residents' beds had bed rails.
Review of Resident 4's medical record indicated she had a physician's order, dated 2/20/24 for, Ok to have
side rails to increase bed mobility. There was no documentation in the medical record that indicated the
facility attempted alternatives prior to installing Resident 4's bed rails.
Review of Resident 20's medical record indicated he had a physician's order, dated 2/21/24 for, Ok to have
side rails for prompt bed mobility. There was no documentation in the medical record that indicated the
facility attempted alternatives prior to installing Resident 20's bed rails. There was also no documentation
that indicated the facility assessed Resident 20 for risk of entrapment.
Review of Resident 21's medical record indicated she had a physician's order, dated 2/20/24 for, OK to
have side rails to increase bed mobility. There was no documentation in the medical record that indicated
the facility attempted alternatives prior to installing Resident 21's bed rails.
Review of Resident 43's medical record indicated he had a physician's order, dated 2/21/24 for, Ok to have
side rails to prompt bed mobility. There was no documentation in the medical record that indicated the
facility attempted alternatives prior to installing Resident 43's bed rails. There was also no documentation
that indicated the facility assessed Resident 43 for risk of entrapment.
During an interview and concurrent record review with the director of nursing (DON) on 2/21/24 at 10:29
a.m., she confirmed the above residents had bed rails. The DON reviewed the medical records of Residents
4, 20, 21, and 43 and confirmed there was no documentation that indicated the facility attempted
alternatives prior to installing their bed rails. The DON also confirmed for Residents 20 and 43, there was
no documentation that indicated the facility assessed for risk of entrapment. The DON acknowledged the
facility was supposed to attempt alternatives prior to installing bed rails and assess for risk of entrapment.
2. During an observation on 2/20/24 at 11:00 a.m., Resident 213 was laying in bed awake, calm, and
comfortable. Resident 213's bed had side rails.
Review of Resident 213's face sheet (a document that gives resident's information at a quick
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 7 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
glance) indicated Resident 213 was admitted to the facility on [DATE].
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident 213's physician order dated 2/20/24 indicated, Resident 213 may have side rails to
increase mobility.
Residents Affected - Some
Review of Resident 213's interdisciplinary team (IDT, a group of professional and direct care staff that work
together to provide residents, the care that they need, when they need it) admission assessment
(comprehensive type of resident evaluation), dated 2/16/24, indicated there was no documentation that the
facility attempted alternatives prior to installing the bed rails.
During an interview and concurrent record review with the DON on 2/23/24 at 2:40 p.m., the DON verified
that Resident 213 had bed rails. She further verified that there was no documentation indicating that the
facility attempted alternatives prior to installing the bed rails of Resident 213. The DON then stated that
documentation should have been done, for the alternatives that were attempted prior to the installation of
the bed rails.
During an observation on 2/20/24 at 11:10 a.m., Resident 32 was laying in bed, alert and comfortable.
Resident 32's bed had side rails.
Review of Resident 32's face sheet indicated, Resident 32 was readmitted to the facility on [DATE].
Review of Resident 32's physician order dated 2/20/24 indicated, Resident 32 may have side rails to
increase mobility.
Review of Resident 32's IDT admission assessment, dated 2/2/24, indicated there was no documentation
that the facility attempted alternatives prior to installing the bed rails.
During an interview and concurrent record review with the DON on 2/23/24 at 2:43 p.m., the DON verified
that Resident 32 had bed rails. She further verified that there was no documentation indicating that the
facility attempted alternatives prior to installing the bed rails of Resident 32. The DON then stated that
documentation should have been done, for the alternatives that were attempted prior to the installation of
the bed rails.
During an observation on 2/20/24 at 1:10 p.m., Resident 47 was up in his chair. Resident 47's bed had side
rails.
Review of Resident 47's face sheet indicated, Resident 47 was readmitted to the facility on [DATE].
Review of Resident 47's physician order dated 2/22/24 indicated, Resident 47 may have side rails to
increase mobility.
Review of Resident 47's IDT admission assessment dated [DATE] indicated, there was no documentation
that the facility attempted alternatives prior to installing the bed rails.
During an interview and concurrent record review with the DON on 2/23/24 at 2:45 p.m., the DON verified
that Resident 47 had bed rails. She further verified that there was no documentation indicating that the
facility attempted alternatives prior to installing the bed rails of Resident 47. The DON then stated that
documentation should have been done, for the alternatives that were attempted prior to the installation of
the bed rails.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 8 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility's policy titled Proper Use of Bed Rails, dated 10/2022 indicated, The medical record
should include an evaluation of alternatives attempted prior to the installation or use of a bed rail and how
these alternatives failed to meet the resident's needs. The policy further indicated, Assessment should
assess resident's risk of entrapment between mattress and bed rail or in the bed rail itself.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 9 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based 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; a kit/box containing medications and supplies for immediate use during
a medical emergency) was not replaced timely after being opened. The failure had the potential for not
having emergency medications/supply on hand when needed for the residents.
Findings:
1. The Controlled Drug Record (CDR) for seven residents receiving PRN (Pro Re Nata, meaning as
needed) controlled medications were requested for review during the survey.
A review of Resident 43's clinical record indicated he had a Physician order for Oxycodone (a controlled
medication for pain) 5 milligrams (mg, unit of measurement) 1 tablet by mouth every 4 hours as needed for
moderate pain and give 2 tablets by mouth every 4 hours as needed for severe pain, dated 2/15/24.
During a concurrent interview and record review on 2/22/24 at 2:34 P.M., with the Director of Nursing
(DON), a review of Resident 43's CDR for Oxycodone and the 2/2024 MAR reflected the nursing staff
removed the medication from the locked controlled medication compartment in the medication cart and
signed out of the CDR on 2/18/24 at 12:51 P.M., but did not document the respective administration on the
MAR. The DON acknowledged that the controlled substance medication was not accounted for in the MAR.
During an interview on 2/26/24 at 3:43 P.M., with Licensed Vocational Nurse (LVN) B, LVN B stated the
controlled substance medication are counted and entered in the CDR. Then the controlled substance
medication should be documented in the MAR. LVN B stated that the CDR and MAR should match. LVN B
stated that the medication was not administered if not documented in MAR.
During an interview on 2/26/24 at 3:46 P.M., with the DON, the DON stated that if a medication was not
documented in the MAR, that meant it was not given.
A review of the facility's General Dose Preparation and Medication Administration policy, dated 12/1/07,
indicated Document the administration of controlled substances Document necessary medication
administration/treatment information (e.g., when medications are opened, when medications are given on
appropriate forms.
2. During a concurrent observation and interview on 2/20/24 at 10:12 A.M., with Registered Nurse
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 10 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
(RN) C in the Medication Room, the orals e-kit (one containing oral medications) was observed unlocked
without any seal. A review of the e-kit log outside the kit indicated one item (Kefzol, an antibiotic) was taken
out on 2/16/24. RN C stated that when a medication was taken out of the e-kit, the withdrawal form must be
faxed to the pharmacy. RN C stated the e-kit is usually replaced within 24 hours.
During an interview on 2/23/24 at 2:34 P.M., with the DON, the DON stated that the withdrawal form on the
opened e-kit should be faxed to the pharmacy and the e-kit replaced within 72 hours. The DON stated that
e-kits should be locked with a red seal once opened.
During an interview on 2/26/24 at 8:34 A.M., with the DON, the DON stated that non-narcotic e-kit does not
need to be replaced within 72 hours.
During a review of the facility's Emergency Supplies of Medications policy, dated 12/1/07, indicated 4.1
Facility staff breaking the lock or tamper evident seal on the emergency kit should replace the lock with a
tamper -evident lock or seal provided by the pharmacy and located in the emergency kit 17. For facilities
served by the following pharmacies the exchange schedule will be set at a minimum of 7 days (weekly) or
the state minimum if shorter, (e.g., a state requires Emergency Kit exchange must occur every 72 hours): .
17.3 Omnicare of Northern California .
According to Title 22 Licensing and Certification of Health Facilities and Referral Agencies, Section 72377
(2) Pharmaceutical Service - Equipment and Supplies, indicated Drugs used from the kit shall be replaced
within 72 hours and the supply resealed by the pharmacist.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 11 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based 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.
Findings:
1. During an inspection of the medication refrigerator at Station 2 on 2/20/24 at 10:12 a.m. with Registered
Nurse (RN) C, the temperature logs indicated one type of vaccine, insulin and, infusion therapy products.
The medication refrigerator temperature was not monitored twice a day. RN C acknowledged the
temperature was not monitored twice a day.
During a concurrent interview and record review, on 2/22/24 at 9:45 a.m., with the Director of Nursing
(DON), the DON confirmed that the medication refrigerator temperature monitoring was not consistently
done twice a day. The DON stated no documentation on the temperature logs meant, it was not done.
2. During an inspection on 2/20/24 at 11:09 a.m. of Station 1 Medication Cart with RN D, RN D identified
and verified, a resident's own medications which were brought from home were stored in a biohazard bag
with no label. RN D stated the medications were placed in a biohazard bag to identify the resident's own
medications and not mixed with the active stock. RN D, further stated the medications should not be placed
in a biohazard bag and should be labeled.
3. During an observation on 2/20/24 at 11:09 a.m. with RN D, RN D identified and verified three nasal
sprays without labels in the Station 1 Medication Cart.
During an observation on 2/20/24 at 11:27 a.m. with RN D, RN D identified and verified, two nasal sprays
without labels in the Station 2 Medication Cart.
During an interview on 2/26/24 at 11:46 a.m. with the Director of Nursing (DON), the DON stated nasal
sprays should be labeled and intended for single resident use. The DON also stated that a resident's own
medications should be stored in a box or plastic bag and should be labeled. The DON further stated, it
should not be placed in a biohazard bag.
Review of the facility's Storage and Expiration of Medications, Biologicals, Syringes and Needles policy,
dated 12/1/07, indicated, 11. Facility staff should monitor the temperature of vaccines twice
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 12 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
a day 14.1 Facility should ensure that infusion therapy products are stored at the appropriate temperature
in a medication-only refrigerator .
Review of the facility's Medications Brought to Facility by the Resident/Family/Physician/Prescriber policy
dated 12/1/07 indicated, 1. Facility staff should not administer medications .brought to the facility by a
resident, a resident's family, or a resident's physician/prescriber, unless: . 1.2 The medication containers are
clearly labeled . 2. Non-prescription medications must be kept in original container and identified with
resident's name.
Event ID:
Facility ID:
055646
If continuation sheet
Page 13 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0806
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food that accommodates resident allergies,
intolerances, and preferences, as well as appealing options.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings:
Review of Resident 114's medical record indicated she was admitted on [DATE] and had diagnoses that
included diabetes (disease that affects the body's ability to control blood sugar) and muscle weakness.
During an interview with Resident 114 on 2/20/24 at 12:09 p.m., she stated the facility would serve her
eggs in the morning, even though she requested not to have eggs.
During an observation and concurrent interview with Resident 114 on 2/26/24 at 8:10 a.m., accompanied
by the director of nursing (DON), there were scrambled eggs on Resident 114's breakfast plate. Resident
114's tray ticket (piece of paper that shows the resident's diet order, likes, and dislikes) indicated to serve
no eggs at all. The DON confirmed this observation. Resident 114 stated the facility served her eggs every
morning.
The facility's policy titled Resident Food Preferences, effective 11/2016 indicated, Satisfy resident's tastes
and appetites by determining and providing their food preferences at meals.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 14 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and document review, the facility failed to ensure food was stored in
accordance with professional standards for food service safety when:
Residents Affected - Many
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.
Findings:
1. During an observation and concurrent interview with the dietary manager (DM) on 2/20/24 at
approximately 8:56 a.m., there was one unlabeled and undated crate of oranges and apples in the dry
storage area of the kitchen. The DM confirmed this observation and stated everything should have a label
with the date the food was received.
The facility's undated document titled Cook Training/Orientation Checklist indicated, Cover, date, and label
stored foods.
2. During an observation and concurrent interview with the DM on 2/20/24 at approximately 8:58 a.m., there
was a dented can of kidney beans in the dry storage area of the kitchen. The dented can was stored
together with non-dented cans that were intended for resident consumption. The DM confirmed this
observation and explained there was a designated area in his office where dented cans should be placed.
The facility's policy titled Food Receiving, dated 2/2009 indicated, When unpacking items, you must inspect
goods for damage. If you have dented cans or open packages, label them do not use and put them in the
supervisor's office to be sent back to the supplier for credit.
3. During an observation and concurrent interview with the registered dietician (RD) on 2/20/24 at
approximately 9:05 a.m., three reach-in freezers in the kitchen were inspected. The reach-in freezers had a
small screen on the outside that displayed the freezer temperatures. One of the three reach-in freezers had
an internal thermometer. The other two reach-in freezers did not have an internal thermometer. The RD
confirmed this observation, but was not sure if the reach-in freezers needed to have internal thermometers.
The facility's policy titled Food Safety In Receiving and Storage, dated 2/2009 indicated, A thermometer will
be kept in each refrigerator and freezer unit. Cooler and freezer temperatures will be checked and recorded
daily, using the internal thermometers.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 15 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
The facility's undated policy titled Food & Dining Services Equipment Cleaning Procedures indicated,
Freezer: . 5. Verify that there is a thermometer inside the unit.
4. During an observation and concurrent interview with the DM on 2/20/24 at approximately 9:20 a.m., the
kitchen's reach-in refrigerator was inspected. The reach-in refrigerator had multiple metal racks with food
stored on them. There were multiple brown crusty substances spread throughout all of the metal racks. The
DM confirmed this observation.
During a follow-up observation and concurrent interview with the DM on 2/21/24 at 8:02 a.m., the kitchen's
reach-in refrigerator was inspected again. The brown crusty substances were no longer on the metal racks.
The DM confirmed these were the same metal racks from the previous day, but they had been cleaned with
soap and water.
The United States Food and Drug Administration's 2022 Food Code indicated equipment shall be clean to
sight and touch.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 16 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0814
Dispose of garbage and refuse properly.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Many
Findings:
During an observation and concurrent interview with the dietary manager (DM) and registered dietician
(RD) on 2/21/24 at 8:15 a.m., the facility's outside dumpsters were inspected. There was one dumpster
designated for garbage. This dumpster had garbage bags inside that were situated in such a way that the
bags were stacked above the dumpster's brim, and the dumpster lid was not able to close. Both the DM and
the RD confirmed this observation. The DM looked inside the garbage dumpster and stated there was
actually more room inside. The DM rearranged the garbage bags and the dumpster lid was then able to
close. The RD confirmed the lid to the garbage dumpster should have been closed.
The facility's policy titled Garbage & Rubbish Disposal, dated 2/2009 indicated, 2. All containers are
provided with tight-fitting lids or covers 5. Garbage and rubbish containing food waste shall be stored so as
to be inaccessible to vermin 8. Outside dumpsters provided by garbage pickup services must be kept
closed and free of litter around the dumpster area.
The United States Food and Drug Administration's 2022 Food Code indicated, Refuse [waste], recyclables,
and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to
insects and rodents. The Food Code further indicated, Outside receptacles must be constructed with
tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or
the entry of rodents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 17 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. 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).
Residents Affected - Some
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.
During an observation and concurrent interview with licensed vocational nurse A (LVN A) on 2/20/24 at
approximately 1:05 p.m., LVN A entered Resident 57's room and confirmed his bottle of Osmolite 1.5 and
the attached GT administration tubing were unlabeled and undated.
During an interview with the director of nursing (DON) on 2/20/24 at 1:20 p.m., she confirmed GT formula
bottles and administration tubings were supposed to be labeled and dated so staff would know how long
they have been in use.
During an observation on 2/26/24 at 12:46 p.m., an unopened bottle of Osmolite 1.5 and an unopened GT
administration tubing package were inspected. On the bottle of Osmolite 1.5, there was a label with
sections designated to write the resident's name, room number, the date, start time, and formula infusion
rate. Inside the GT administration tubing package, there was a label with sections designated to write the
resident's name, room number, formula, date and time, and expiration date.
Based on observation, interview, and record review, the facility failed to ensure infection control practices
were implemented when:
1. Resident 163's unlabeled nebulizer mask [(similar to a regular oxygen mask; it covers the mouth and
nose and is usually held onto the face using an elastic band, the nebulizer is used to deliver liquid
medication via inhalation to the lungs by converting the liquid drug into a fine mist) tubing and the Bi-level
Positive Airway Pressure (BIPAP, machine that help push pressurized air into the lungs) mask tubings were
exposed and touching the bedside table and, the oxygen (O2) nasal cannula (NC, a plastic tubing that
delivers oxygen) tubing was not labeled.
1a. Resident 163's unlabeled nebulizer face mask tubing, BIPAP mask tubing, O2 - NC tubing and suction
tubing were touching the urinal.
1b. Resident 44 is on contact isolation (a combination of practices used to prevent germs from spreading)
due to Clostridium difficile (C. diff., a bacterium which can infect and make humans ill) and her commode
was outside her room next to the isolation cart.
1c. Housekeeping cart bucket has two unlabeled plastic bottle sprays with liquids inside approximately 800
ml. (milliliter, a unit of measure) each spray bottle and one box opened gloves inside the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 18 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
plastic container with eight pairs of gloves outside the box together with pen, cell phone and notebook.
Level of Harm - Minimal harm
or potential for actual harm
2. For Resident 57, the gastrostomy tube (GT, a feeding tube surgically inserted through the abdomen and
into the stomach) formula and administration tubing were unlabeled and undated;
Residents Affected - Some
3. Open suture removal kit, laptop with charger and mouse, skin protectant and wound dressing supplies
stored in one drawer of the treatment cart.
3a. Nasal cannula tied on the side rails without a date and not placed in a plastic bag for Resident 38.
3b. Urinary catheter drainage bag without a privacy bag.
These failures could result in the spread of infection and cross-contamination that could affect the 60
residents who reside in the facility.
Findings:
1. During an initial tour of the facility on 2/20/24 at 9:01 a.m., Resident 163's nebulizer mask tubing, BIPAP
mask tubing and O2 NC, were not labeled with a date to indicate when the tubings were applied or
changed and were touching the bedside table.
During a concurrent observation and interview on 2/20/24, at 9:17 a.m., with the infection preventionist (IP),
she acknowledged the above observation and stated that nebulizer mask tubing, BIPAP mask tubing and
O2 NC, should not be touching the bedside table surface and it should be put inside the plastic bag for
good infection control practice.
During a concurrent interview and record review on 2/23/24 at 10:05 a.m., with the director of nursing
(DON), She reviewed Resident 163's clinical records and stated that Physician order dated 2/19/24
indicated 02 at 2-4 Liter/ minute (L/Min.) via NC, continuous every shift, change 02 tubing monthly every
night shift (every 28 days), BIPAP on at 9:00 p.m., and off at 9:00 a.m., and wash BIPAP tubing, headgear,
and whisper swivel adapter (if utilized) weekly - every Sunday. DON further stated that 02 NC, BIPAP and
nebulizer tubings should have been labeled when the tubing was applied or changed, and stored in a clean
plastic bag if not used.
1a. During an initial tour of the facility on 2/20/24 at 9:13 a.m., Resident 163's nebulizer mask tubing, BIPAP
mask tubing, suction machine tubing and O2 NC tubing, were touching the urinal.
During a concurrent observation and interview on 2/20/24, at 9:17 a.m., with the infection preventionist (IP),
she acknowledged the above observation and stated that they should not be touching the urinal due to
infection control issue.
Review of the facility's policy and procedure titled CPAP/BIPAP Cleaning revised 6/15/2023 indicated, 2.
Respiratory therapy equipment can become colonized with infectious organisms and serve as a source of
respiratory infections. 3. Staff shall perform hand hygiene and wear gloves whenever touching the
CPAP/BIPAP equipment 6. clean mask frame daily after use with CPAP (continuous positive airway
pressure, a machine that uses mild air pressure to keep breathing airways open while one is asleep)/BIPAP
cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 19 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
machine storage when not in use.
Level of Harm - Minimal harm
or potential for actual harm
1b. During an initial tour of the facility on 2/20/24 at 9:02 a.m., a commode was outside Resident 44's room
next to the isolation cart.
Residents Affected - Some
During a concurrent observation and interview on 2/20/24 at 9:03 a.m., with the housekeeper E (HKE),
HKE stated that the commode was used by resident 44 and was cleaned this morning.
During a concurrent observation and interview on 2/20/24 at 9:03 a.m., with the IP, she confirmed the
above observation and stated that Resident 44 is on contact isolation due to C. diff. and Resident 44's
bedside commode should not be outside her room next to the isolation cart due to infection control issue
and she further stated that the staff should follow the contact precaution protocol for all residents in contact
isolation.
1c. During a concurrent observation and interview on 2/20/24 at 9:04 a.m., with the HKE she acknowledged
there were two unlabeled plastic bottle sprays with liquids inside and one box opened, gloves inside the
plastic container with eight pairs of gloves outside the box together with pen, cell phone and notebook in
the housekeeping cart.
During a concurrent observation and interview on 2/20/24 at 9:14 a.m., with the IP, she confirmed the
above observation and stated that the staff should follow the infection control protocol for all residents in
order to prevent the spread of infections in the facility.
Review of the facility's policy and procedure titled Safe, Clean, Comfortable, and Homelike Environment
dated 6/2023, indicated in accordance with residents' rights, the facility will strive to provide a safe, clean,
comfortable and home like environment .10. The facility will strive to maintain/enhance a safe, clean,
comfortable environment by engaging in the following general practices and consideration: . c. Properly
labeling and /or storing personal/ADL supplies when not in use e. maintaining chemicals, cleaning agents,
and biologicals in a safe and secured manner.
3. During an observation on 2/20/24 at 10:58 a.m. with Registered Nurse (RN) C, of the treatment cart, the
treatment cart was observed with an open suture removal kit, laptop with the charger and mouse mixed
with skin protectant and wound dressing supplies in one of its drawers.
During an interview on 2/20/24 at 10:58 a.m., with the Director of Nursing (DON), the DON stated that an
open suture removal kit, laptop with charger and mouse should not be mixed with the skin protectant and
wound dressing supplies in a drawer in the treatment cart.
During an interview on 2/23/24 at 11:36 p.m., with Infection Preventionist (IP), IP stated that the open
package of suture removal kit, laptop, charger, and mouse should not be in the treatment cart to prevent
spread of infection. IP stated that the open suture removal kit should be discarded once opened and not
kept in the treatment cart.
Review of the facility's Safe, Clean, Comfortable, and Homelike Environment policy, dated 6/2023, indicated
10. The facility will strive to maintain/enhance a safe, clean, comfortable environment by engaging in the
following general practices and consideration: . e. maintaining chemicals, cleaning agents, and biologicals
in a safe and secured manner.
Review of the facility's Storage and Expiration of Medications, Biologicals, Syringes and Needles
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 20 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
policy, dated 12/1/07 indicated, 3.5 Topical (external) use medications or other medications should be
stored separately .when infection control issues may be a consideration.
3a. During an observation on 2/20/24 at 1:03 p.m., Resident 38 was observed lying in bed with a nasal
cannula tied around the side rails without a date and not placed in a bag.
Residents Affected - Some
During an interview on 2/20/24 at 2:55 p.m., with the DON, the DON stated that oxygen tubing is changed
every 30 days and must be labeled with the date it was changed. The DON stated that nasal cannula tubing
must be placed in a bag when not in use by the resident.
Review of the facility's Oxygen Administration policy, dated August 2014, indicated 5. g. Label humidifier
with date and time opened. Change humidifier and tubing per facility procedure 10. At regular intervals,
check and clean oxygen equipment, masks, tubing and cannula.
3b. During an observation on 2/20/24 at 1:35 p.m., Resident 54 was in bed with the urinary catheter
drainage bag without a privacy bag.
During a concurrent observation and interview on 2/20/24 at 1:43 p.m., with Licensed Vocational Nurse
(LVN) A, LVN A confirmed that the urinary drainage bag has no privacy bag.
During an interview on 2/20/24 at 1:50 p.m. with the IP, the IP confirmed that the urinary catheter drainage
bag has no privacy bag. IP stated that there should always be a privacy bag.
Review of the facility's Catheter Care policy, dated 1/11/22, indicated Privacy bags will be available and
catheter drainage bag will be covered at all times while in use.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 21 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0912
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
Based 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.
Findings:
The room measurement indicated multiple rooms were less than 80 square feet per resident.
Room Number Number of Beds Square Feet
Per Resident
1 3 72.8
5 2 71.37
7 2 71.95
9 2 75
12 3 73.2
14 3 73.2
15 3 73.2
16 3 74
17 3 74
18 2 75
19 2 73.2
20 2 74.4
23 3 73.2
24 3 73.6
25 3 73.6
27 3 73.6
29 3 73.2
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 22 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0912
Level of Harm - Potential for
minimal harm
During the survey, residents and staff were observed and interviewed to determine if there were any
concerns or issues with the lack of space or privacy. The residents and staff verbalized no complaints or
concerns regarding space and privacy affecting residents' care.
Recommend to continue room waivers.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 23 of 24
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055646
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palo Alto Post-Acute
911 Bryant Street
Palo Alto, CA 94301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Few
Findings:
During an interview with Resident 43 on 2/22/24 at 1:12 p.m., he stated the facility's call light system was
not functioning properly. Resident 43 stated the buttons do not work.
During an observation and concurrent interview with the director of maintenance (DOM) on 2/23/24 at 9:24
a.m., Bathroom AA was inspected. This was a bathroom shared by residents in two rooms. One of these
rooms had three residents and the other had two residents. The DOM entered Bathroom AA and pushed
the button that was supposed to activate the call light system. The call light in the hallway did not turn on.
The DOM confirmed this observation.
During a follow-up observation and concurrent interview with the DOM on 2/26/24 at 9:55 a.m. (three days
after the original observation of Bathroom AA), the DOM entered Bathroom AA and pushed the button that
was supposed to activate the call light system. The call light in the hallway did not turn on. The DOM
confirmed this observation.
The facility's policy titled Call Lights: Accessibility and Timely Response, revised 11/30/23 indicated, The
purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's
bedside, toilet, and bathing facility to allow residents to call for assistance.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055646
If continuation sheet
Page 24 of 24
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Back to topCitations
11 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
F919 - Resident Call System
Make sure that a working call system is available in each resident's bathroom and bathing area.
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
FAQ · About this visit
Common questions about this visit
What happened during the February 26, 2024 survey of Palo Alto Post-Acute?
This was a inspection survey of Palo Alto Post-Acute on February 26, 2024. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Palo Alto Post-Acute on February 26, 2024?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.