Health inspection·January 10, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan for one of 34 sampled residents (Resident 1) that includes the instructions needed to provide effective and person-centered care when there was an intervention which was not applicable upon admission for Resident 1 who was at risk for fall. This failure had the potential to place Resident 1 at risk not to receive the appropriate intervention to prevent fall. Findings: Review of Resident 1's admission Record indicated, she was admitted to the facility on [DATE] with diagnoses including encephalopathy (a group of conditions that cause brain dysfunction), presence of left artificial hip joint, and orthostatic hypotension (a drop in blood pressure that occurs when moving from a laying down position to a standing position). Review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 3/19/23 indicated, she was cognitively intact. The MDS also indicated, Resident 1 had hip fracture (a partial or complete break in the bone), displacement intertrochanteric fractures of left femur (a kind of the change in position and fracture of thigh bone), and history of falling. During a concurrent interview and record review on 1/10/24 at 10:45 a.m. with Director of Nursing (DON), Resident 1's fall score and Radiology Report were reviewed. DON stated, She fell at home, then she had a hip fracture. She had ORIF (Open Reduction and Internal Fixation, a type of surgery used to stabilize and heal a broken bone), then she came to us for rehab . DON stated, the resident's fall score was 13 upon admission on [DATE]. DON stated, a fall score above 10 was at risk for fall. DON stated, Resident 1 had unwitnessed fall on 4/12/23 around 4:45 p.m. DON stated, Resident 1 was sitting in wheelchair, and it was locked for her safety. DON stated, her bed was next to Resident 1, and a table was in front of her because she was waiting for her dinner, then she had unwitnessed fall. DON stated, We don't know why. She couldn't tell us why she fell. DON stated, there was a small skin tear on the left thumb, and it was not bleeding. Otherwise, there was no injury. DON stated, during the neuro check (an evaluation of a person's nervous system), Resident 1 was noted skin discoloration on her right mid back, and that's why the doctor ordered stat X-ray. DON stated, otherwise Resident 1 was fine. DON stated, We ordered stat X-ray on 4/12, then it was done next day, then had a result on 4/14. Radiology Report dated 4/13/23 indicated, . Right 7th rib fracture . DON stated, they sent her to the hospital, but she refused treatment, so she returned the same day. So, we monitored her for her safety. DON stated, Resident 1 left the facility at 10:30 a.m. on 4/14/23 without chief (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 2 Event ID: 555827 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 555827 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atherton Park Post-Acute 1275 Crane Street Menlo Park, CA 94025 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)