Deficiency Records for Palo Alto Sub-Acute and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Palo Alto Sub-Acute and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2024-01-31 | 2024-03-02 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-08-29 | 2022-09-20 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-04-08 | 2022-05-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-08 | 2022-05-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-08 | 2022-05-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-04-08 | 2022-05-08 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-04-08 | 2022-05-08 | N |
| 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. | Health | 2022-04-08 | 2022-05-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-08 | 2022-05-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-08 | 2022-05-08 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-04-08 | 2022-05-08 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-04-12 | 2022-04-28 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-04-12 | 2022-04-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-04-12 | 2022-04-28 | N |
| Use approved construction type or materials. | Fire Safety | 2022-04-12 | 2022-04-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-12 | 2022-04-28 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-04-12 | 2022-04-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-04-12 | 2022-04-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-04-12 | 2022-04-28 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-04-12 | 2022-04-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-12 | 2022-04-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-12 | 2022-04-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-12 | 2022-04-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-04-12 | 2022-04-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-12 | 2022-04-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-12 | 2022-04-28 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-04-12 | 2022-04-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-12 | 2022-04-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-22 | 2022-01-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-22 | 2022-01-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-22 | 2022-01-22 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-07-27 | 2021-08-28 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-07-27 | 2021-08-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-27 | 2021-08-28 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2019-07-16 | 2019-08-07 | N |
| Use approved construction type or materials. | Fire Safety | 2019-07-16 | 2019-08-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-16 | 2019-08-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-07-16 | 2019-08-07 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-07-16 | 2019-08-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-16 | 2019-08-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-16 | 2019-08-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-16 | 2019-08-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-16 | 2019-08-07 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-05-09 | 2019-05-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-09 | 2019-05-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-05-09 | 2019-05-30 | N |
| 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. | Health | 2019-05-09 | 2019-05-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-09 | 2019-05-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-09 | 2019-05-30 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-05-09 | 2019-05-30 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-05-09 | 2019-05-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-09 | 2018-05-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-09 | 2018-05-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-05-09 | 2018-05-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-09 | 2018-05-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-05-09 | 2018-05-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-04-05 | 2018-05-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-04-05 | 2018-05-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-04-05 | 2018-05-01 | N |
| 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. | Health | 2018-04-05 | 2018-05-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-05 | 2018-05-01 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-04-05 | 2018-05-01 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2018-04-05 | 2018-05-01 | N |
