Palo Alto Post-Acute

In the surveyor’s words

From the most serious findings on record at Palo Alto Post-Acute, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF804May 30, 2025

  Based on observation, interview and record review, the facility failed to ensure palatability and temperature of the foods served were maintained when: 1. The pureed (a smooth, thick liquid or paste made by crushing or grinding solid foods using a blender or food processor) fish and pureed bread tasted bland (lacking taste or flavor); and 2. The temperature of the hot foods served were below the desired level. These failures could lead to decreased nutrient intake for the 55 facility residents receiving food from the kitchen. Findings: 1. During the test tray observation and tasting with the dietary manager (DM), on 5/28/25 at 12:45 p.m. to 12:52 p.m., two test plates in the trays were brought and tasted. […]

• No harm, potential for more than minimal, widespreadF812May 30, 2025

  Based on observation, interview, and record review, the facility failed to ensure, cooking and kitchen equipment were maintained properly and foods in the kitchen were prepared in accordance with professional standards for food safety when: 1. There were unsanitary cooking and kitchen equipment stored in the kitchen and, 2. Kitchen staff did not perform hand hygiene and sanitation during the tray line preparation. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness (illness resulting from contaminated food) and cross-contaminated food for the 55 residents who received food from the facility kitchen. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF812Feb 26, 2024

  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: 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. […]

• No harm, potential for more than minimal, widespreadF814Feb 26, 2024

  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. 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. […]

• No harm, potential for more than minimal, patternF880May 30, 2025

  2a. Review of Resident 53's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 53's physician order, dated 5/25/25, indicated she had an order for oxygen 2-3 liters per minute (LPM) as needed for shortness of breath. During an observation and interview with the infection preventionist (IP) on 5/27/25, at 10:46 a.m., the filter of Resident 53's oxygen concentrator was dusty. The IP confirmed the filter was dusty and stated the filter should be cleansed every week. 2b. […]