Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stanford Court Skilled Nursing & Rehab Center during CMS and state inspections, most recent first.
Failure to Provide Written Advance Directive Information: The facility did not document that written advance directive information was provided to 6 sampled residents. For each resident, the Advance Directive Acknowledgement form was left blank and the record contained no evidence that the brochure was given or refused. The DON confirmed that written documentation was not provided, and the facility policy stated that the resident or representative is to be provided written information to formulate an advance directive.
Hot water temperatures in multiple resident rooms and a shower area exceeded safe limits. During observation with the ESD, sink water measured as high as 152 F and shower water measured 125 F, while one resident reported the sink water had always been hot since admission. Record review showed the facility's daily logs only documented two water heaters even though four supplied resident rooms, and the thermometer on one water heater was broken.
Delayed medication administration and documentation occurred for three residents when a scheduled anxiolytic was charted nearly 4 hours late and two other medications were removed from locked storage well before their MAR documentation times. An LN and the DON confirmed there was no explanation in the record for the delays, and the DON stated MAR entries were expected immediately after administration, including for controlled medications.
A resident with an NG-tube and surgical aftercare diagnosis reported daily diarrhea since admission. Although orders for PEG, docusate, and psyllium husk said to hold for loose stool, LNs administered these laxatives multiple times after loose, watery, or putty-like stools were documented. LN acknowledged the meds should have been held, and the DON stated nurses should have assessed bowel status before giving them.
Food safety practices were not followed when the dietary manager was observed in the kitchen with exposed facial hair and no beard guard while overseeing the breakfast tray line. Staff also used a broken thermometer to check hot food temperatures, and final temperatures were not consistently taken or documented before lasagna and other foods were placed on the tray line and served; the DM and RD stated all food items were expected to have final temperatures taken before service.
Failure to Implement Nail Care Care Plan: A resident with needs for personal care and mobility assistance had long, yellow, discolored fingernails despite repeated requests to have them cut and filed. The care plan noted a preference to keep nails long and included an intervention to offer filing, but LN, CNA, and DON interviews confirmed the nail care intervention was not implemented and the resident’s ADL care plan for nail care was not followed.
Failure to provide needed nail care for a resident who required assistance with ADLs. The resident’s fingernails were observed to be long, yellow, and discolored, and the resident stated she had repeatedly asked staff to cut and file them shorter. Staff interviews confirmed the nails should have been trimmed or filed for hygiene, grooming, and to prevent scratching, and the DON stated the nail care should have been provided.
A resident with an NG tube and orders for multiple constipation-prevention medications had repeated loose, watery, and putty-like stools documented, yet nurses continued to administer laxatives and stool softeners. LN 11 acknowledged the resident was having loose stools and the medications should have been held. The DON stated nurses should have checked the resident’s bowel movements, PCC, and CNA input before giving the medications, and the bowel assessment in-service did not include all of the involved LNs.
An unlocked medication cart was observed unattended in a hallway near resident rooms. An LPN stated the cart was not hers and should not have been left unsecured, while the assigned LPN later stated she forgot to lock it and that residents and unauthorized staff could have accessed the medications inside. The DON confirmed medication carts should be locked when the assigned nurse is not present, and the facility policy required medication carts and compartments to be locked when not in use.
Kitchen staff failed to demonstrate competency in thermometer use and final food temperature checks. One staff member used a digital thermometer that would not calibrate properly and continued using it for hot foods, while both she and a kitchen assistant served lasagna without taking or recording final temperatures. Their competency records stated they should use thermometers correctly and check and record temperatures before service, but interviews confirmed neither staff member followed those steps.
Failure to Follow Posted Lunch Menu: During lunch tray line, several residents were plated meals that did not include the mixed vegetables listed on the menu. Residents reported they sometimes received food that was not on the menu and wanted the menu followed. The DM and RD stated the menu was expected to be followed and residents should have been served what they expected on the menu.
A nurse used the same blood pressure cuff on three residents without disinfecting it between uses, despite staff and the DON stating it should be cleaned after each resident. The facility also failed to properly clean and disinfect a resident’s PureWick components; staff were unsure when the cannister and tubing were last cleaned, the IP said there was no policy for the device, and the facility policy did not address cleaning and disinfecting the canister, lid, tubing, or pump tubing as required by the manufacturer.
The facility failed to provide dedicated vital signs equipment for two residents with C. diff infections, as required by their care plans and facility policy. Observations revealed the absence of such equipment in the residents' rooms, despite signs indicating the need for contact precautions. Interviews with staff confirmed the expectation for dedicated equipment to prevent infection spread.
The facility failed to follow proper infection control practices for two COVID-19 positive residents. Staff were observed wearing an N-95 mask over a surgical mask, compromising its effectiveness, and entering rooms without required face shields. Interviews confirmed these practices were against facility policy, which mandates proper PPE, including an N-95 mask, gown, gloves, and eye protection.
A facility failed to create a resident-centered care plan for a resident at high risk for falls. Despite a Fall Risk Evaluation indicating the high risk, the care plan did not reflect this. The Clinical Care Coordinator acknowledged the oversight, highlighting the importance of individualized care plans. The facility's policy requires care plans to be based on assessments and developed by an interdisciplinary team.
A facility failed to update a resident's care plan to reflect their high fall risk, despite assessments indicating increased risk. The resident, with hemiplegia and hemiparesis, was assessed as high risk for falls on multiple occasions, but the care plan still showed a moderate risk. The Clinical Care Coordinator acknowledged the discrepancy, noting the importance of accurate care plans for staff to prevent falls. The facility's policy lacked guidance on care plan revisions.
A resident, identified as high risk for falls due to conditions like morbid obesity and mobility issues, experienced a fall. The facility failed to conduct a thorough investigation to determine the cause of the fall and implement specific interventions. The Clinical Care Coordinator admitted the investigation was insufficient, not exploring the resident's actions leading to the fall, contrary to the facility's policy requiring cause identification within 24 hours.
The facility failed to provide palatable and flavorful meals, leading to resident dissatisfaction and potential nutritional issues. Residents reported repetitive menus, particularly with chicken, and meals often being cold and bland. The Dietary Supervisor and Registered Dietician acknowledged these issues, noting the potential for weight loss due to unappetizing food options.
The facility failed to maintain sanitary practices by using a low-temperature dishwasher that did not reach the required 120 F for proper sanitation. Despite knowing the temperature was insufficient, a Dietary Assistant continued to use the machine without notifying a supervisor. Another Dietary Assistant was aware of the issue but unsure of alternative cleaning methods. The Dietary Supervisor confirmed that staff should have reported the issue and used a three-compartment sink instead.
A resident's dignity was compromised when a staff member instructed them to urinate in a diaper instead of assisting with a bedpan or toilet. The resident, who was continent and typically used a bedpan, reported feeling terrible about the incident. The Director of Nurses confirmed that such instructions are demeaning and against the facility's rehabilitation goals. The facility's policy emphasizes care that promotes dignity and respect.
The facility failed to maintain a homelike environment for three residents due to damaged walls behind their beds. Observations showed scraped and peeling paint and drywall, and residents reported that maintenance had not assessed the damage. Staff were unaware of the issue, and the Environmental Service Director noted that mechanical beds caused the damage. The Director of Nursing acknowledged the importance of timely repairs to support a homelike setting.
A resident with schizoaffective disorder was not re-evaluated for PASARR after admission, despite being on antipsychotic medication. The case manager and DON acknowledged the oversight, noting the resident was not included in the PASARR review calendar, contrary to facility policy requiring such evaluations to ensure appropriate care and placement.
A resident was using a left-hand splint and had triamcinolone ointment without MD orders. The splint was applied by an RNA without documentation, and the ointment was left uncapped on the nightstand, posing risks of misuse. Facility policies require MD orders for such treatments, which were not followed, compromising the resident's care.
A resident with a history of hemiplegia and hemiparesis was found with long, dirty fingernails, indicating a failure in personal hygiene care. Despite being dependent on staff for hygiene, the resident's nail care was neglected, and hand splints were not consistently applied as per orders. Interviews with staff confirmed the lack of sufficient nail care, contrary to the facility's policy.
A resident with hemiplegia did not receive appropriate care as per professional standards. The resident's fingernails were neglected, remaining long and dirty, and the hand splint was not managed according to physician orders. Staff failed to remove the splint within the prescribed timeframe and did not provide necessary nail care, as confirmed by facility staff and policy reviews.
A resident with a peritoneal abscess and sepsis did not receive proper care for their drainage tube, as staff failed to consistently squeeze the accordion bulb to create necessary suction. Observations and interviews revealed a lack of understanding among staff about the correct procedure, leading to a deficiency in care.
The facility failed to securely store medications for two residents, leading to potential misuse and allergic reactions. A discontinued triamcinolone ointment was left uncapped on a resident's nightstand, and a prescribed Salonpas patch was stored at another resident's bedside without a self-administration safety screen. Facility policy requires medications to be stored in locked compartments, which was not followed in these cases.
Two residents in a LTC facility had food brought by family improperly stored, leading to potential health risks. One resident had fruits left at the bedside for over a week, while another had a sandwich, pastries, and a banana improperly stored. Facility policies requiring labeling and refrigeration were not followed, posing risks of spoilage and foodborne illness. Staff interviews confirmed the failure to adhere to these policies.
A facility failed to enforce neutropenic precautions for a resident with a low white blood cell count, allowing raw fruits in the resident's room despite policy prohibiting them. Staff interviews revealed inconsistencies in understanding and enforcing the precautions, with some staff allowing washed fruits and vegetables. The Director of Nursing acknowledged the oversight and emphasized the importance of following the protocol to protect the resident from infection.
A resident with severe cognitive impairment reported being physically abused by staff, but the incidents were not reported immediately as required by facility policy. A CNA witnessed the abuse but delayed reporting due to fear of gossip, leading to a failure in protecting the resident from further harm.
Failure to Provide Written Advance Directive Information
Penalty
Summary
The facility failed to ensure written advance directive information was provided to 6 of 10 sampled residents: Residents 1, 12, 45, 85, 130, and 144. For each resident, the clinical record was reviewed on 12/3/25 and the facility’s Advance Directive Acknowledgement form showed the statement, "I have received the brochure on Advance Directives," left blank. The records contained no documentation that advance directive information had been provided to any of these residents. The residents were admitted to the facility on the dates listed in their admission records, and the deficiency was identified during record review. On 12/04/2025 at 3:28 P.M., the DON stated that written documentation was not provided to these residents. The DON also stated the expectation was that the medical record should show that an Advance Directive brochure was given or refused by the resident, family, and/or representative. The facility policy titled Advance Directive, dated September 2022, stated that advance directives are honored in accordance with state law and facility policy and that the resident or representative is provided with written information to formulate an advance directive.
Hot Water Temperatures Exceeded Safe Limits in Resident Rooms and Shower Area
Penalty
Summary
The facility failed to ensure that water temperatures in nine residents' rooms and in the shower room located by the 500 rooms were below 120 degrees Fahrenheit. During observations with the environmental services director, the water in Resident 134's sink measured 143 F, Resident 140's sink measured 140 F, the sinks in Resident 123, 128, 132, and 113's rooms measured 152 F, the shower room water measured 125 F, and the sinks in Resident 53 and 147's rooms measured 122 F. Resident 134's sink was observed to produce hot water that was steamy and painful to the touch in one second, and the environmental services director stated the temperatures were too hot and dangerously hot. Record review and interview showed the facility's Environmental Daily Logs documented only two water heater temperatures for that day, even though the environmental services director stated there were four water heaters supplying resident rooms. The director stated the log needed to be revised to include a water temperature check of a resident room receiving water from each water heater and said he was unsure which water heater supplied the affected rooms and shower area. The water heater in the activity director's office had a thermostat set at 117 F, but the thermometer installed to test outgoing water was broken. Resident 140 stated the water in the sink was always hot and had been hot since admission, and the administrator stated water temperatures above 120 F were a safety concern.
Delayed Medication Administration and MAR Documentation
Penalty
Summary
The facility failed to provide proper pharmaceutical services for three residents when medication administration and documentation were not completed in accordance with ordered times and facility policy. For one resident with anxiety, busPIRONE 5 mg ordered twice daily at 9 A.M. and 6 P.M. was documented as given at 1:55 P.M. on 11/27/25, which was 3 hours and 55 minutes late. During review with the LN and DON, there was no documentation in the clinical record explaining the delay, and the DON stated nurses were expected to document medication administration immediately after giving the medication and to document the reason for any delay. For a second resident, Lyrica 75 mg ordered once daily for pain was removed from locked storage at 9 A.M. on 11/30/25, but the MAR showed administration at 11:25 A.M. For a third resident with epilepsy, lacosamide 200 mg ordered twice daily at 9 A.M. and 9 P.M. was removed from locked storage at 8:03 A.M. on 12/3/25, but the MAR documented administration at 9:59 A.M. The LN stated she gave the lacosamide with the resident’s morning medications but forgot to document it until 9:59 A.M., and stated she should have documented it immediately after administration. The DON reviewed the records for both residents and stated there was no documentation explaining the delays in the MAR entries. The DON stated nurses should not delay controlled medication administration for even 10 minutes after removal from locked storage and that controlled medications must be administered immediately after removal with timely documentation on the MAR. Facility policies also stated medications are to be administered within one hour of the prescribed time, documented after each medication is given, and that controlled substances require immediate entry of the date and time of administration when removed from controlled storage.
Laxatives Given Despite Loose Stools
Penalty
Summary
The facility failed to ensure Resident 133’s drug regimen was free from unnecessary medications when licensed nurses did not follow physician orders for laxatives on multiple occasions. Resident 133 was admitted with a diagnosis of surgical aftercare following surgery on the nervous system and was observed with an NG-tube. During interview, the resident stated having diarrhea every day since admission and was unsure whether stool softeners or laxatives were being given. Physician orders dated 11/21/25 directed polyethylene glycol 3350 daily, docusate sodium twice daily, and psyllium husk three times daily, each to be held for loose stool. Review of the bowel elimination record and MAR showed the resident had loose, watery, or putty-like stools on several dates, yet laxatives were still administered nine times after those stools were documented. LN 11 stated she should have held the laxatives for Resident 133 and acknowledged the resident was having loose stools when the medications were still given. The DON stated nurses should have assessed bowel movements by asking the resident, checking PCC, and asking the CNA before administering the medications.
Food Safety and Temperature Monitoring Deficiencies
Penalty
Summary
The dietary manager was observed in the kitchen overseeing the breakfast tray line while wearing a surgical mask, but facial hair approximately a half inch long was exposed on both cheeks and he was not wearing a beard guard. During interview, the dietary manager stated he should have worn a beard guard over the surgical mask to cover all facial hair and that beard guards had to be worn over facial hair to prevent hair from getting into food. The facility’s competency form and policy both indicated that hair restraints and beard guards were to be used properly and that beard nets were required when facial hair was visible. A broken digital thermometer was used to take food temperatures during meal service. One staff member calibrated an orange thermometer in ice water and it did not reach 32 F, then stated the thermometer did not calibrate; the dietary manager confirmed the orange thermometer was broken and should not have been used. Despite this, the staff member used that thermometer to take hot food temperatures. In addition, final food temperatures were not consistently taken before food was placed on the tray line and served: chopped lasagna was served without a documented final temperature, and another lasagna brought to the steam table was also served without a final temperature being taken. The dietary manager and registered dietitian stated it was their expectation that final food temperatures be taken on all food items prior to being served to residents.
Failure to Implement Nail Care Care Plan
Penalty
Summary
The facility failed to implement Resident 16’s care plan interventions for activities of daily living related to nail care. Resident 16 was admitted with diagnoses including an unspecified fracture of the fifth lumbar vertebra, need for assistance with personal care, and abnormalities of gait and mobility. During an observation and interview, Resident 16 was lying in bed watching TV, and her fingernails were observed to be long, about 1/2 inch in length, yellow, and discolored. Resident 16 stated she preferred long fingernails but that they were too long now and needed to be cut, and she reported telling staff many times that she wanted her fingernails cut and filed shorter. She also stated her fingernails had only been cut once since admission. The resident’s care plan problem for activities of daily living routine and/or preferences indicated she preferred to keep her fingernails long, with an intervention to offer to file her nails. Interviews with LN 16, CNA 17, LN 18, and the DON confirmed that the resident’s nails should have been cut or filed when requested and for hygiene purposes, and that the ADL care plan related to nail care was not implemented. The facility policy stated that a comprehensive, person-centered care plan is developed and implemented for each resident and describes the services to be furnished.
Failure to Provide Needed Nail Care
Penalty
Summary
The facility failed to provide necessary nail care to maintain good grooming and personal hygiene for one resident. The resident was admitted with diagnoses including unspecified fracture of the fifth lumbar vertebra, need for assistance with personal care, and abnormalities of gait and mobility. During an observation and interview, the resident was lying in bed watching TV and her fingernails were observed to be approximately 1/2 inch long, yellow, and discolored. The resident stated she preferred long fingernails but that they were too long and needed to be cut, and she reported telling staff many times that she wanted her fingernails cut and filed shorter. She also stated her fingernails had only been cut once since admission. The resident’s care plan identified that she preferred to keep her fingernails long and included an intervention to offer to file her nails. A licensed nurse stated that when the resident requested nail care, the CNA would have been expected to cut and file the fingernails. A CNA observed the resident’s long fingernails and stated they should have been filed or cut for hygiene and to prevent scratching and infection. Another licensed nurse stated the resident’s fingernails were long and yellowing and should have been offered nail care for hygiene purposes, and the DON stated the resident’s nail care should have been provided. The facility policy stated nail care includes daily cleaning and regular trimming, and the ADL policy stated residents unable to perform ADLs independently will receive services necessary to maintain good grooming and personal and oral hygiene.
Laxatives Given Despite Loose Stools
Penalty
Summary
The facility failed to ensure six of six licensed nurses were competent to assess bowel eliminations and administer laxatives for a resident who had an NG tube and was admitted for surgical aftercare following surgery on the nervous system. The resident stated he had diarrhea every day since admission and was unsure whether he was receiving stool softeners or laxatives. His physician orders included polyethylene glycol 3350 daily, docusate sodium twice daily, and psyllium husk three times daily, each ordered for constipation prevention and to be held for loose stool. Record review showed multiple instances in which the resident had loose, watery, or putty-like stools documented on the bowel elimination record, yet laxatives were still administered afterward. Examples included polyethylene glycol, docusate sodium, and psyllium husk being given on days when the resident had documented loose or watery stools earlier that same day or on prior shifts. During interview, LN 11 stated she would check the resident’s bowel movements and records if the resident was not alert enough to report them, but acknowledged that the resident was having loose stools and laxatives were still given. LN 11 stated the laxatives should have been held. The MAR showed laxatives were administered by LN 21, LN 22, LN 23, LN 24, and LN 25 on multiple occasions despite the documented stool pattern. The DON stated licensed nurses should have asked the resident about bowel movements, checked the PCC dashboard, and asked the CNA about bowel movements before administering laxatives. The DON also stated she provided an in-service on bowel assessment and laxatives, but no written posttest was required. The in-service attendance record showed LN 22 and LN 24 were not listed as attendees, while LN 11, LN 21, LN 23, and LN 25 attended.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure one medication cart was locked when unattended. On 12/1/25 at 2:45 P.M., a medication cart was observed unattended and unlocked in the hallway by the 500 series resident rooms. LN 1, who was walking down the hall after leaving a resident's room, stated the cart was not assigned to her and that it should not have been left unsecured in the hallway. On 12/3/25 at 3:33 P.M., LN 2 stated the unlocked cart was her assigned medication cart and that she forgot to lock it. LN 2 stated residents and unauthorized staff could have gained access to the medications inside the cart and that it was her responsibility to ensure the cart was locked when not in use. On 12/4/25 at 3:05 P.M., the DON stated medication carts should be locked when the assigned nurse is not present. The facility policy titled Medication Labeling and Storage stated that compartments containing medications and biologicals are locked when not in use and carts used to transport such items are not left unattended if open or otherwise potentially available to others.
Kitchen Staff Failed to Properly Calibrate Thermometer and Record Final Food Temperatures
Penalty
Summary
The facility failed to ensure two kitchen staff members were competent in taking final food temperatures and using the thermometer correctly. During an observation in the kitchen, one staff member was seen calibrating a digital thermometer in ice water, but the orange thermometer shut off at 33 degrees Fahrenheit and did not reach 32 degrees Fahrenheit. The staff member stated the thermometer did not calibrate, and a second thermometer was provided that calibrated properly. Despite being told the orange thermometer was broken and should not be used, the staff member continued using it to take temperatures of food placed on the steam table and stated she always used that thermometer for hot food. Later that morning, the same staff member was observed serving chopped lasagna without being observed taking its final temperature, and she stated she did not write the temperature down because there was no space on the form. Another kitchen assistant was observed placing lasagna on the steam table and was also not observed taking the final temperature. When interviewed, the assistant stated she did not take the final temperature and did not write it down. Record review showed both staff members had competency checklists stating they used thermometers correctly to check food temperatures and checked and recorded temperatures prior to service. The director of maintenance and registered dietitian stated the competency checklist did not address thermometer calibration, that the staff member had not been competent, and that final food temperatures should have been taken on all food items prior to service.
Failure to Follow Posted Lunch Menu
Penalty
Summary
The facility failed to follow the lunch menu during tray line service. A confidential group interview with eight residents revealed that they sometimes received food that was not on the menu and wanted the menu to be followed. The lunch menu for 12/3/25 listed meat lasagna, marinara sauce, garlic bread, mixed vegetables, sorbet, and 2% milk, but during a kitchen observation several residents' meals were plated and placed in the meal cart without mixed vegetables. The dietary manager stated that mixed vegetables were on the menu and should have been served, while another staff member stated they were not on the menu and that garden salad was to be served instead. The dietary manager and the registered dietitian later stated it was their expectation that the menu be followed and that residents should have been served what they expected on the menu. The facility policy titled Policy & Procedure Manual Menu Planning dated 2023 did not provide guidance related to following the menu.
Failure to disinfect shared equipment and PureWick components
Penalty
Summary
The facility failed to follow infection prevention and control practices when a nurse used the same manual blood pressure cuff on three residents without disinfecting it between uses. Resident 20 was admitted with hypertensive heart disease and heart failure, Resident 85 was admitted with hypertensive heart disease, and Resident 132 was admitted with hypertension. During observation, Licensed Nurse 12 checked Resident 132’s blood pressure, returned the cuff to the medication cart without disinfecting it, then used the same cuff on Resident 20 and Resident 85, again placing it back in the cart without cleaning it between residents. During the observation, the nurse did not disinfect the blood pressure cuff after each resident use. Later interviews confirmed that blood pressure cuffs should be disinfected after every use with a disinfecting cloth, and the nurse stated she should have cleaned the cuff after each resident use to prevent infections. The Director of Nursing stated she expected nursing staff to disinfect blood pressure cuffs after each use and identified this as important for infection prevention control. The facility policy on cleaning and disinfection of resident care items and equipment stated reusable items are cleaned and disinfected or sterilized between residents. The facility also failed to properly clean and disinfect a PureWick device used by Resident 124. Resident 124 had diagnoses including urinary tract infection and need for assistance with personal care, and her care plan and treatment orders directed that the PureWick be changed nightly and removed after breakfast. During observation, tubing from the PureWick was in use, but the resident did not know when it had last been changed and was unsure whether staff cleaned the container. A nurse stated she was not sure when the cannister and collection tubing were cleaned and disinfected, and the Infection Preventionist stated the facility did not have a policy on the PureWick device. The manufacturer’s directions stated the collection canister, canister lid, collector tubing, and pump tubing should be cleaned and disinfected after each use, but the facility policy did not address cleaning and disinfecting those components.
Failure to Provide Dedicated Equipment for Residents with C. diff
Penalty
Summary
The facility failed to ensure proper infection control practices by not designating dedicated vital signs (VS) equipment for two residents with Clostridium difficile (C. diff) infections. During observations, it was noted that the rooms of both residents had signs indicating the need for contact precautions and the use of dedicated or disposable equipment. However, the Certified Nurse Assistant (CNA) was unable to find any VS equipment in the rooms or on the carts outside the rooms. The care plans for both residents indicated the requirement for dedicated equipment due to their C. diff infections, but this was not adhered to. Interviews with facility staff, including a Licensed Nurse (LN), the Infection Preventionist (IP), and the Director of Nursing (DON), confirmed that dedicated VS equipment should have been available in the isolation rooms to prevent the spread of infection. The facility's policy on Clostridium Difficile, dated October 2018, also emphasized the importance of using dedicated medical equipment to prevent transmission. The lack of dedicated VS equipment for these residents posed a risk of spreading the infection throughout the facility.
Inadequate Infection Control Practices for COVID-19 Positive Residents
Penalty
Summary
The facility failed to adhere to current infection control practices for two residents who tested positive for COVID-19. Staff members were observed wearing an N-95 mask over a surgical mask, which was against the facility's policy and compromised the effectiveness of the N-95 mask. Certified Nurse Assistants (CNAs) and Licensed Nurses (LNs) were seen entering rooms of COVID-19 positive residents with improper personal protective equipment (PPE). Specifically, CNAs were observed wearing an N-95 mask over a surgical mask, and one LN entered a COVID-19 positive resident's room without a face shield, despite the precaution sign indicating the need for eye protection. Interviews with staff, including the Infection Prevention Nurse (IPN) and the Director of Nurses (DON), confirmed that the practice of double masking with an N-95 over a surgical mask was incorrect and compromised the seal of the N-95 mask. The IPN also stated that prescription glasses were not a substitute for a face shield, which was required for additional protection. The facility's policy, dated November 2024, clearly outlined the need for proper PPE, including an N-95 mask, gown, gloves, and eye protection, when entering the room of a resident with suspected or confirmed COVID-19 infection.
Failure to Develop Resident-Centered Care Plan for Fall Risk
Penalty
Summary
The facility failed to develop a resident-centered care plan for a resident identified as being at high risk for falls. This deficiency was identified during a review of the care plan for a resident who was readmitted to the facility with diagnoses including abnormalities of gait and mobility. Despite a Fall Risk Evaluation indicating the resident was at high risk for falls, the care plan did not reflect this risk. During an interview and joint record review, the Clinical Care Coordinator acknowledged that the care plan did not address the resident's individual concerns and needs, emphasizing the importance of developing a care plan tailored to each resident's specific requirements. The facility's policy on care planning, revised in March 2022, mandates that comprehensive, person-centered care plans be based on resident assessments and developed by an interdisciplinary team.
Failure to Revise Resident's Fall Risk Care Plan
Penalty
Summary
The facility failed to revise the care plan for a resident concerning their fall risk, which was identified during an interview and record review. The resident, who was readmitted with diagnoses of hemiplegia and hemiparesis, had a fall risk assessment indicating a moderate risk on 12/26/23, which later assessments on 2/20/24, 3/20/24, and 6/17/24 showed as high risk. However, the care plan dated 8/11/23 still reflected a moderate risk for falls. During an interview on 8/16/24, the Clinical Care Coordinator acknowledged that the care plan did not reflect the resident's current fall risk, which was necessary for staff to implement appropriate interventions to prevent falls. The facility's policy on care planning did not provide guidance on revising care plans.
Inadequate Fall Investigation for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident was free from future falls by not conducting a thorough investigation of the resident's fall. The resident, who was admitted with diagnoses including diverticulitis, morbid obesity, and gait and mobility abnormalities, was identified as high risk for falls. The resident experienced a fall and reported attempting to brace herself before falling. During an interview, the Clinical Care Coordinator acknowledged that the investigation into the fall was not thorough, as it did not explore what the resident was attempting to do when she tried to stand. The facility's policy requires identifying possible causes of falls within 24 hours, which was not adequately followed in this case.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, flavorful, and maintained its nutritional value, as observed during dining observations and interviews. Residents expressed dissatisfaction with the repetitive menu, particularly the frequent serving of chicken, and noted that meals were often cold and lacked flavor. Some residents reported relying on food brought by family members due to the unappetizing meals provided by the facility. The facility's menu on a specific date included pot roast and pureed options, which were found to be bland and salty during a test tray observation with the Dietary Supervisor. The facility's policy on taste testing, dated 2017, was not adhered to, as food that did not pass the taste test due to seasoning or other negative factors was still served. The Dietary Supervisor and Registered Dietician acknowledged the issues with the menu and the potential for weight loss among residents due to the lack of palatable food options. The Registered Dietician noted the need for a better nutritional menu equivalency for different meal textures, as residents were not receiving the planned menu items.
Improper Use of Low-Temperature Dishwasher
Penalty
Summary
The facility failed to maintain sanitary practices in the kitchen, specifically in the use of a low-temperature dishwasher. During an observation, it was noted that the dishwasher's temperature gauge read 111 F, below the required 120 F necessary for proper sanitation. Despite this, the Dietary Assistant (DA) 1 continued to use the machine without notifying a supervisor, contrary to the facility's policy. DA 1 acknowledged that the temperature was insufficient to kill germs and bacteria, yet proceeded to wash and store dishes as if they were sanitized. Further interviews revealed that another Dietary Assistant (DA 2) was also aware of the inadequate temperature but was unsure of alternative methods to clean the dishes if the dishwasher was not functioning properly. The Dietary Supervisor confirmed that staff should have reported the issue and used a three-compartment sink as an alternative. The failure to adhere to these procedures posed a risk of foodborne illness to the 90 residents served by the kitchen.
Resident Dignity Compromised by Inappropriate Care Instructions
Penalty
Summary
The facility failed to ensure that a resident's dignity was maintained when a staff member instructed the resident to urinate in a diaper instead of providing assistance to use a bedpan or toilet. Resident 178, who was admitted with a need for assistance with personal care, reported feeling terrible after being told to urinate in the diaper. The resident was continent and typically used a bedpan, as confirmed by CNA 11. This incident was observed and reported during interviews with the resident and staff. The Director of Nurses acknowledged that residents should not be instructed to urinate in diapers, as it is demeaning and contrary to the facility's rehabilitation goals. The facility's policy on dignity, dated June 16, 2016, emphasizes that residents should be cared for in a manner that promotes dignity, respect, and individuality. The care plan for Resident 178 indicated a need for assistance with toileting, highlighting the importance of providing appropriate support during activities of daily living.
Failure to Maintain Homelike Environment Due to Wall Damage
Penalty
Summary
The facility failed to provide a homelike environment for three residents due to damaged walls in their rooms. Observations revealed that the walls behind the beds of these residents were in disrepair, with paint and drywall scraped and peeling. Interviews with the residents indicated that maintenance had not assessed or repaired the damage, despite the residents' awareness of the issue. Staff members, including a CNA and an LN, were unaware of the disrepair and stated that the process for requesting maintenance involved filling out a repair slip at the nurse's station. The Environmental Service Director (ESD) was also unaware of the damage and explained that the mechanical beds were causing the scraping. The ESD mentioned that plastic protection sheets were being used to prevent further damage but acknowledged that complete repairs would require moving residents out of their rooms. The Director of Nursing (DON) confirmed that the damaged walls did not provide a homelike environment and emphasized the importance of timely communication with maintenance for repairs. The facility's policy on maintaining a homelike environment highlighted the need for a clean, sanitary, and orderly setting, which was not upheld in this instance.
Failure to Re-evaluate PASARR for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to re-evaluate a resident for the Pre-Admission Screening and Resident Review (PASARR), which is a federal requirement to ensure individuals with mental illness, developmental disability, or intellectual disability are appropriately placed in nursing homes. The resident in question was admitted with a diagnosis of schizoaffective disorder and was on antipsychotic medication. Despite these indicators, the resident was not included in the facility's PASARR review calendar for the month following their admission. The case manager acknowledged that a PASARR Level I review should have been conducted at the facility, given the resident's diagnosis and medication. The Director of Nurses also confirmed that the PASARR should have been re-evaluated to ensure the resident received proper care and to determine if a different placement was necessary. The facility's policy and procedure on PASARR indicated that such screenings are essential to determine the appropriateness of nursing facility care and the need for specialized services, but this was not adhered to in this case.
Failure to Obtain MD Orders for Splint and Medication Use
Penalty
Summary
The facility failed to provide services meeting professional standards of practice for Resident 47, who was using a left-hand splint without a Medical Doctor's (MD) order. Resident 47, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was observed using the splint without proper documentation or orders. The Restorative Nursing Assistant (RNA) applied the splint but did not chart its use due to the absence of an MD order, which is required for such devices. The Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that all splints need MD orders to ensure proper monitoring and prevent complications. Additionally, Resident 47 was found to have triamcinolone ointment on their nightstand without an MD order. The ointment, used to treat skin irritation, was left uncapped and accessible, posing a risk of misuse or allergic reactions. The licensed nurse (LN) and DSD confirmed that all treatments, including ointments, require MD orders and should be stored securely. The ointment was not prescribed, and there was no evaluation for self-administration, leading to its improper storage and potential for cross-contamination. The facility's policies require MD orders for both splint use and medication administration, which were not followed in these instances. The lack of proper orders and documentation for the splint and ointment use highlights a failure in adhering to professional standards, potentially compromising Resident 47's safety and care.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide necessary care to maintain good grooming and personal hygiene for a resident who required dependent assistance. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was observed with long, thick, yellowish-brown fingernails with dirt-like debris underneath and old chipped nail polish. Despite having no cognitive deficits, the resident was dependent on staff for personal hygiene. Observations and interviews revealed that the resident's hand splint was not consistently applied as per the physician's orders, and nail care was neglected. Interviews with the restorative nursing assistant and the Director of Staff Development confirmed that the resident's nail care was insufficient, as the nails were long and dirty. The Director of Nursing also acknowledged that the resident was not receiving appropriate nail care. The facility's policy on nail care, which includes daily cleaning and regular trimming to prevent infections, was not followed, leading to the deficiency in maintaining the resident's personal hygiene.
Deficiency in Care for Resident with Hemiplegia
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards for Resident 15, who required dependent assistance. Resident 15 was readmitted with a history of hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side. Despite having no cognitive deficits, Resident 15 was dependent on staff for personal hygiene. Observations revealed that Resident 15's fingernails were long, thick, yellowish brown, with debris underneath, and old chipped nail polish, indicating a lack of nail care. Additionally, Resident 15's left hand, which required a splint due to contracture, was not consistently managed according to physician orders. On multiple occasions, Resident 15 reported that the staff only applied the hand splint sporadically and could not recall the last time nail care was provided. Observations confirmed that the splint was not removed within the prescribed four to six hours, and hand hygiene was neglected. The restorative nursing assistant acknowledged the oversight, noting that the splint was applied at 10:15 A.M. on one day and was not removed until the following day, contrary to the physician's orders. The assistant also admitted that Resident 15's nails were dirty and should have been cleaned and clipped. Interviews with the Director of Staff Development and the Director of Nursing corroborated the findings. They confirmed that the splint should have been removed within the specified timeframe and that nail care should have been provided. The facility's policy required that dependent residents receive necessary services to maintain grooming and hygiene, which was not adhered to in this case. The Director of Nursing emphasized the importance of following physician orders to prevent risks such as skin breakdown and infection, which were not adequately addressed for Resident 15.
Inadequate Care of Resident's Drainage Tube
Penalty
Summary
The facility failed to appropriately care for a resident's drainage tube, which was necessary for managing a peritoneal abscess and sepsis. The resident, who was admitted with these conditions, reported that the staff did not properly maintain the drainage tube, specifically noting that the accordion bulb had not been squeezed for two days. Observations confirmed that the bulb was not squeezed, which is essential for creating suction to drain fluid effectively. The physician's orders and hospital records indicated that the bulb should be squeezed to prevent infection and promote healing. Interviews with nursing staff revealed inconsistencies in understanding and executing the care required for the drainage tube. The treatment nurse stated that the bulb must be squeezed to create suction, while another nurse incorrectly believed the drain worked by gravity and did not require squeezing. The Director of Nurses confirmed that the bulb should be squeezed to remove fluids, aligning with the facility's policy on maintaining negative pressure for drainage. This lack of consistent and correct practice among staff members led to the deficiency in care for the resident's drainage tube.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications securely for two residents, leading to potential risks of medication misuse and allergic reactions. For one resident, a discontinued order for triamcinolone ointment was found uncapped and unsecured on the nightstand table. Despite the resident having no cognitive deficits, the ointment was left unattended, and there were no current orders for its use in the resident's clinical chart. Interviews with the Licensed Nurse and Director of Staff Development confirmed that the ointment should have been discarded or stored securely in a treatment cart. Another resident had a prescribed Salonpas pain patch stored on the bedside table without a self-administration safety screen. The resident had mild cognitive deficits, and the presence of the medication at the bedside was inappropriate as it required safe application and proper storage to maintain its effectiveness. The Licensed Nurse and Director of Staff Development acknowledged that the Salonpas should have been stored in the medication cart due to the lack of a self-administration evaluation. The facility's policy on medication labeling and storage, revised in February 2023, mandates that all medications and biologicals be stored in locked compartments with access limited to authorized personnel. The Director of Nursing reiterated the importance of storing medications securely to prevent misuse and preserve their effectiveness, highlighting the potential for severe allergic reactions if not properly monitored and administered.
Improper Storage of Outside Food in LTC Facility
Penalty
Summary
The facility failed to store foods brought by family and visitors in a safe and sanitary manner according to their policies and procedures, affecting two residents. Resident 59 had a bag of unlabeled apples and oranges placed at the bedside for over a week. Despite the resident's cognitive ability to understand the situation, the fruits were not stored properly, posing a risk of spoilage and foodborne illness. The facility's policy required such items to be labeled and stored in a refrigerator, but this was not followed. Additionally, the presence of fresh fruits and flowers in the room was inappropriate due to the roommate's neutropenic precautions, which require a sterile environment to prevent infection. Resident 47 also had unlabeled and improperly stored food items at the bedside, including a sandwich, chocolate pastries, and a banana. These items were not stored in a refrigerator or labeled as required by the facility's policy. The resident expressed dissatisfaction with the facility's food, leading to the family bringing outside food. However, the lack of proper storage and labeling increased the risk of spoilage and foodborne illness. The facility's policy mandates that perishable foods be stored in resealable containers with tightly fitting lids and labeled with the resident's name and use-by date. Interviews with staff, including a licensed nurse, the Director of Staff Development, and the Director of Nursing, confirmed the failure to adhere to the facility's policies. The staff acknowledged that the food items should have been stored in the designated refrigerator and labeled appropriately. The failure to follow these procedures not only posed health risks to the residents but also highlighted a lack of communication and enforcement of the facility's food storage policies.
Failure to Enforce Neutropenic Precautions
Penalty
Summary
The facility failed to maintain appropriate neutropenic precautions for Resident 58, who was admitted with a diagnosis of malignant neoplasm of the endometrium and had a low white blood cell count, making her prone to infections. Despite signage indicating neutropenic precautions, raw fruits were found in the room shared by Resident 58 and her roommate, Resident 59. Resident 59's daughter had brought the fruits weeks prior, and they were only removed after being noticed by state surveyors. Interviews with staff revealed inconsistencies in understanding and enforcing the neutropenic precautions, with some staff allowing washed fruits and vegetables, contrary to the facility's policy. The facility's policy, dated April 2018, clearly prohibited raw and partially cooked fruits and vegetables, as well as plants and flowers, in rooms of residents on neutropenic precautions. However, there was a lack of adherence to these guidelines, as evidenced by the presence of raw fruits in the room. Staff interviews indicated a lack of consistent enforcement of PPE use and visitor protocols, with some visitors not following gowning procedures. The Director of Nursing acknowledged the oversight and emphasized the importance of following the neutropenic protocol to protect Resident 58 from potential infection.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of an abuse allegation involving a resident with severe cognitive impairment. The resident, who was admitted with metabolic encephalopathy, reported being physically abused by staff members. The Director of Nurses (DON) was informed of the abuse by a licensed nurse (LN) two days after the incidents occurred. The abuse was witnessed by a certified nurse assistant (CNA) who did not report the incidents immediately due to fear of gossip, contrary to the facility's policy requiring immediate reporting within two hours. The incidents involved a CNA witnessing another CNA physically assaulting the resident on two separate occasions. The first incident involved the resident being slapped and sustaining a cut on the hand, while the second involved the resident being pushed and choked. Despite witnessing these events, the CNA delayed reporting them to the charge nurse until the following day. The facility's policy mandates immediate reporting of abuse allegations to prevent further harm to residents, which was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 622 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Santee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgemoor Hospital | 1.2 mi | ★★★★★ | 19 | 1 |
| Bradley Court | 2.1 mi | ★★★★★ | 0 | 0 |
| Parkside Health And Wellness Center | 3 mi | ★★★★★ | 0 | 0 |
| Somerset Subacute And Care | 3.1 mi | ★★★★★ | 2 | 0 |
| Lakeside Special Care Center | 3.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.