Health inspection·May 23, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure windows on the 2ndfloor were: Residents Affected - Some 1. Secure from opening greater than 4 inches to prevent confused residents from jumping out windows. 2. Inspected on a regular basis to ensure window securing devices were still functioning. 3. Secure window with a device that is tamper proof. Failure to secure 2nd floor windows had the potential for confused residents to sustain serious injuries if they jump out of these windows. Findings: During observation on 05/23/2025 at 11:15 AM with the Administrator, windows in rooms 209, 212, 216 on the second floor were found without any device to limit how wide they could be opened. These windows could be opened to their full limit of at least 30 inches. These observations were confirmed with the Administrator. During an interview on 05/23/2025 at 11:30 AM, the Administrator stated there should be a mechanical limiter on those windows so that the windows could not be opened fully. The Administrator was asked to: 1. Conduct an audit of the entire 2nd and 3rd floor to see if there were other windows with the same issue. 2. Provide their policy regarding securing windows. 3. Provide a sample of the device they used to limit window openings. During an interview on 05/23/2025 at 12:18 PM, the Assistant Maintenance Worker (AMW) explained the window limiting devices were a thumb screw that could be removed by staff to enable them to clean the windows. The AMW stated he checked all the windows once a week but does not document these checks. The AMW stated sometimes residents as well as visitors may remove these window limiters to open the window wider. The AMW was asked how wide these windows should opened to with a window limiter. The AMW stated 3 inches. (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 05/23/2025 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)