VI at Palo Alto

In the surveyor’s words

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

• Actual harm, isolatedF689Mar 22, 2024

  Based on interview and record review, the facility failed to provide adequate assessment and supervision to prevent an accident for one of three residents (Resident 1) when physical therapy (PT, a healthcare profession that helps you move better or strengthen weakened muscles) did not follow physician's orders to assess Resident 1's functional ability level upon admission and develop a resident-centered plan of care. This resulted in Resident 1's fall, head injuries, multiple fractures, and subsequent death. […]

• No harm, potential for more than minimal, patternF802Jan 26, 2026

  Based on observation, interview, and record review the facility failed to ensure Kitchen Staff F (KS F) used proper technique when testing sanitizer concentration for cleaning food contact surfaces. This failure had the potential to increase the risk of contamination and exposure to food borne illness for 37 residents in the facility.Findings: During a kitchen observation on 1/22/26, at 10:10 a.m., KS F was observed checking the sanitizer bucket used for cleaning food contact surfaces. KS F dipped the sanitizer test strip into the sanitizer solution and immediately removed the test strip. KS F did not allow the test strip to remain in the solution for the required contact time. […]

• No harm, potential for more than minimal, patternF700Aug 23, 2024

  Based on observation, interview, and record review, the facility failed to follow their restraint protocol and ensure the proper use of side rails or bed canes (adjustable rigid bars attached to the side of a bed) for nine (Residents 1, 12, 22, 26, 32, 33, 191, 243, and 246) of 24 residents (residents who used side rails or bed canes) when: 1. Resident 1 there was no physician order, side rail assessment, consent, or care plan for the use of side rails; 2. For Resident 243 there was no physician order or care plan for the use of bed canes; 3. For Resident 246 there was no physician order for the use of bed canes; 4. For Resident 191 there was no physician order or care plan for the use of bed canes; 5. For Resident 12 there was no physician order or consent for the use of bed canes; 6. […]

• No harm, potential for more than minimal, patternF812Aug 23, 2024

  Based on observation, interview and record review, the facility failed to ensure food was stored in accordance with professional standards for food safety when: 1. There was an opened undated food item in the pantry freezer; 2. There were open and undated food items, and unopened food items with no expiration dates in the dry storage area of the main kitchen. These failures had the potential to cause food contamination and food-borne illness to 37 of 37 residents who received their food from the kitchen. 1. During an initial kitchen tour on 8/19/24 at 9:20 a.m., accompanied by the Executive Chef (EC), inside the reach-in freezer there was an opened, undated container of mango sorbet. […]

• No harm, potential for more than minimal, patternF812Mar 17, 2023

  Based on observation, interview, and document review, the facility failed to ensure food was stored and prepared under sanitary conditions when: 1. There were unlabeled and undated food items in the kitchen refrigerator and blast chiller (equipment that quickly lowers food temperature); 2. There were dented cans of food in the dry storage area of the kitchen; 3. There was a black substance on the inside of one out of two ice machines; and 4. Kitchen attendant B (KA B) did not follow printed instructions when testing the surface sanitizer (solution used to kill microorganisms on kitchen surfaces). These failures had the potential to cause food contamination and illness for all residents who received food from the kitchen (34 of 35 residents). Findings: 1. […]