Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stanford Crossing during CMS and state inspections, most recent first.
Failure to Notify MD and Family of Significant Change in Condition: Staff did not promptly notify the MD or resident representative when a resident with DM, ASHD, and full code status had decreased PO intake, low fluid intake, and a change in LOC/mental status. CNA, LPN, and RN observations showed the resident was sleepy, not opening eyes, and not eating or drinking, but there was no documented notification until the resident became unresponsive and was sent to the hospital, where she was diagnosed with intracerebral hemorrhage, sepsis, and pneumonia.
A resident with diabetes, heart disease, dementia, and malnutrition had several days of poor PO and fluid intake, along with worsening lethargy, unresponsiveness, and abnormal breathing. Staff reported the changes, but there was no documented thorough nursing assessment or timely MD notification when the resident stopped eating and drinking and became difficult to arouse. The resident was later sent to the hospital, diagnosed with intracerebral hemorrhage, sepsis, and pneumonia, intubated, transferred to a trauma center, and died.
Incomplete Documentation of Resident Decline: The facility failed to document nursing assessments and notes for a resident who had markedly decreased food and fluid intake and a change in level of consciousness. Staff reported the resident was sleeping more than usual, not eating or drinking, and not opening eyes, but the record lacked assessments during the decline. An RN later documented only a temperature of 97.5 degrees, while EMS found the resident hot to touch with a temperature of 104.2 degrees before transfer to the hospital, where the resident was diagnosed with intracerebral hemorrhage, sepsis, and pneumonia and later expired.
The facility failed to maintain enough nursing staff to meet resident needs, and residents and CNAs reported that care was often delayed because staff were rushed and short-handed. A resident said nighttime bathroom assistance was slow, another said medications were sometimes late, and others reported long waits for call lights, late snacks, and missed or delayed care tasks. Surveyors observed call lights left on for 18 and 24 minutes, while CNAs described heavy assignments, difficulty completing showers and two-person assists, and the DON and Administrator acknowledged frequent call-ins and staffing shortages.
A facility failed to provide housekeeping services to keep resident rooms clean and sanitary, with multiple rooms showing cracked tiles, holes in walls and drywall, a loose bathroom handrail, a sharp-edged overbed table, and black substance on a baseboard. A resident reported a broken tile had been present since admission and sometimes trapped a wheelchair wheel, while staff including the DON, Housekeeping Manager, Maintenance Director, and Administrator said they were unaware of several of the conditions and noted that work orders could be entered through the Tails system.
Failure to develop and update person-centered comprehensive care plans for two residents. One resident had a low BIMS score and diagnoses including prior TIA/stroke, cerebral infarction, and difficulty walking, but the care plan was not resident-specific and was not updated quarterly. Another resident admitted for rehab after an ischemic stroke had no personalized care plan, and the goal to return home was not tailored because the resident had been homeless; the care plan was also not updated quarterly.
The facility failed to follow infection control practices for a resident on EBP and for residents using nebulizer equipment. A CNA provided care without donning PPE first and left the room without hand hygiene, while nebulizer tubing and kits for several residents were observed out of the required bagged storage when not in use. Staff interviews confirmed the expected use of gloves and gowns for EBP and proper storage of nebulizer tubing.
A nurse administered multiple medications intended for one resident to another after failing to properly identify the correct individual, following a room and bed switch that was not promptly updated in the system. The nurse relied only on room numbers rather than verifying the resident's identity, resulting in a significant medication error. Facility leadership confirmed that proper identification protocols were not followed.
Failure to Notify Physician and Representative of Significant Change in Condition
Penalty
Summary
The facility failed to immediately inform the resident’s physician and resident representative when there was a significant change in the resident’s physical and mental status for one sampled resident, R19. R19 had diagnoses including diabetes and atherosclerotic heart disease, was cognitively intact with a BIMS score of 14, and had a full code status. The care plan included keeping the family informed of changes in condition. The facility assessed R19 to have decreased meal and fluid intake over several days, including refusal of meals and low fluid intake, but there was no documented evidence that the physician or representative was notified of the decline. Staff interviews showed multiple observations of change in condition without notification to the physician or representative. A CNA stated R19 would not open her eyes and was clamping her mouth closed during oral care, and that nursing staff were told about the change. An LPN stated R19 did not eat or drink and slept a lot during the shift, and an RN stated R19 slept quite a bit and was not acting normally. Despite these observations, there was no documented evidence that the physician or representative was notified of the resident’s decreased intake or change in mental status. An APRN stated she had not been notified until the resident had a change in level of consciousness and was unresponsive to sternal rubs with fixed and pinpoint pupils, at which point she instructed staff to transfer the resident to the hospital. The resident was later sent to the emergency department, where the hospital diagnosed intracerebral hemorrhage, sepsis, and pneumonia. The resident was intubated and transferred to a Level 1 Trauma Center for further treatment, and later expired. The resident’s family member stated she was not contacted until late at night when staff reported breathing trouble and poor intake, and she was told at the hospital that the resident had been unresponsive and had not eaten for three days. The Medical Director stated he had not been informed of the resident’s condition at any point and expected notification of a resident’s change in condition, especially when a full code resident had not eaten or drank for 24 hours.
Failure to Assess and Report Resident Decline in Intake and Responsiveness
Penalty
Summary
The facility failed to ensure that a resident with diabetes, atherosclerotic heart disease, dementia, and protein-calorie malnutrition received treatment and care in accordance with the comprehensive person-centered care plan and professional standards of practice. The resident’s care plan included interventions to assess for dehydration, encourage additional fluids four times daily, monitor and document oral intake, and report signs of dysphagia or hyperglycemia, including stupor or coma. The facility also had policies requiring notification of the physician and representative for significant changes in condition, including deterioration in physical or mental status. The resident had decreased meal and fluid intake over several days, including refusal of breakfast and lunch, minimal dinner intake, refusal of all meals on one day, and continued poor intake afterward. Fluid intake was documented as low on multiple days. Despite these findings, there was no documented evidence that staff completed a thorough nursing assessment related to the decline in food and fluid intake, and there was no documented evidence that the physician was notified of the decreased appetite or fluid intake. Staff interviews indicated that the resident was also noted to be increasingly sleepy, not opening her eyes, not responding normally, and later having abnormal, heavy, fast breathing, but these changes were not documented as having been thoroughly assessed when first observed. Multiple staff members reported observing the resident’s decline in condition. A CNA stated she notified nursing staff that the resident would not open her eyes and clamped her mouth shut during oral care. Another CNA stated she later reported that the resident was not responsive and had abnormal breathing, and that an RN obtained an oxygen saturation of 65%. An LPN stated the resident did not eat or drink and slept a lot during the shift, but the physician was not notified. Another RN stated the resident slept quite a bit and was sleepy during the shift, but there was no documented evidence of a thorough assessment or physician notification. The resident was eventually transferred to the hospital, where she was diagnosed with intracerebral hemorrhage, sepsis, and pneumonia, intubated, transferred to a Level 1 Trauma Center, and later expired.
Incomplete Documentation of Resident Decline
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for one sampled resident, R19, by not documenting assessments when the resident had a decline in intake and level of consciousness from 11/24/2025 through 11/27/2025. R19 had been admitted on 01/13/2016 and had diagnoses including diabetes and atherosclerotic heart disease. The care plan identified nutritional and hydration risk, with interventions to assess for signs and symptoms of dehydration, monitor oral intake, and document and report signs of dysphagia or refusal to eat, as well as to monitor for physical or mental decline and keep the family informed of changes in condition. Record review showed R19 refused breakfast and lunch on 11/24/2025, consumed 0-25% of dinner on 11/24/2025 and 11/25/2025, refused all meals on 11/26/2025, consumed 0-25% of breakfast and lunch on 11/27/2025, and refused dinner on 11/27/2025. Fluid intake was also low, with totals documented as 700 ml on 11/24/2025, 120 ml on 11/26/2025, and 420 ml on 11/27/2025. Despite these declines, there was no documented evidence that nursing assessments were completed during this period, and there were no nursing notes from 11/24/2025 through 11/27/2025. Staff interviews confirmed concerns about R19's condition. A CNA stated she notified nursing staff that R19 would not open her eyes but did clamp her mouth closed during oral care, and said a nurse obtained vital signs and told her they were normal, though no assessment or vital signs were documented. An LPN and an RN stated R19 was sleeping a lot and not eating or drinking, and an RN stated staff reported R19 was sleepy during the shift, but there was no documented assessment. RN5 stated she assessed R19 after being notified of a change in level of consciousness shortly before calling 911, yet the only note entered was at 12:30 AM on 11/28/2025 documenting a temperature of 97.5 degrees Fahrenheit. EMS later documented R19's temperature as 104.2 degrees and that the resident was hot to touch. R19 was transferred to the hospital, diagnosed with intracerebral hemorrhage, sepsis, and pneumonia, and expired on 12/04/2025.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to ensure it had sufficient nursing staff to meet resident needs and to have a licensed nurse in charge on each shift, affecting 6 of 51 sampled residents. The facility’s staffing policy stated it was intended to provide sufficient staff with appropriate competencies to assure resident safety and maintain resident well-being, and that nurse aides must be competent to care for residents’ needs as identified in assessments and care plans. Review of the facility’s Payroll Based Journal report showed a one-star staffing rating, indicating the facility had not met the minimum staffing set by CMS. Residents and staff described delays in care that they attributed to inadequate staffing. One resident who took a fluid pill said she needed multiple bathroom trips at night and had to wait longer for assistance. Another resident reported medications were sometimes given later than scheduled because of a lack of staff. Other residents stated that call lights were answered slowly, staff appeared rushed, and nighttime snacks were frequently late. One resident said aides were sitting in the dining area instead of answering call lights, and another said he had to go into the hallway to seek help for his roommate after the call light had been on for a while. Observations confirmed delayed response to call lights, including one that remained illuminated for 24 minutes before a CNA responded and another that remained on for 18 minutes before response. CNAs stated they were busy with other residents, thought someone else had answered, or were unable to complete all required care. One CNA reported being responsible for up to 25 residents per shift and having difficulty finding help for two-person assists, while another said she often could not follow the shower schedule due to lack of time. The DON acknowledged frequent call-ins and said department heads helped provide care, and the Administrator stated the facility averaged 38 staff call-ins per month, used mass texts and scheduler calls to fill shifts, and relied on department heads to cover when needed. The Administrator also acknowledged resident concerns about call-light response times and stated her expectation was that call lights be answered within 5 to 10 minutes or acknowledged by staff.
Failure to Maintain Clean and Safe Resident Rooms
Penalty
Summary
The facility failed to provide housekeeping services to ensure a clean and sanitary environment for eight sampled residents, based on observation, interview, and policy review. The facility’s Resident Rights policy stated residents had a right to a safe, clean, comfortable, and homelike environment, and the Housekeeping Daily Duties policy stated that all corners and along all baseboards must be dust mopped to prevent buildup. During observations, multiple resident rooms had environmental and maintenance issues, including cracked tiles in doorways or bathrooms, a loose bathroom handrail missing a screw, a two-inch hole in a wall behind a bed, a broken tile in the middle of a room, a one-inch gap in drywall around a sink, numerous holes in drywall on all four walls, and an overbed table with missing rubber exposing a sharp edge. A black substance was observed on a baseboard in one resident’s room, and the resident stated it had been there for a long time and made the resident feel dirty. Another resident reported that a broken tile had been present since admission and that a wheelchair wheel sometimes got stuck in the hole. A trash can was also observed under a sink in one room to catch dripping water, and the resident stated they did not know when it would be fixed. The Maintenance Director, DON, Housekeeping Manager, Housekeeper, and Administrator each stated they were unaware of several of the observed conditions, and both the Maintenance Director and Administrator stated that staff could enter work orders into the Tails system, but no active work orders were present at the time of interview.
Failure to Develop and Update Person-Centered Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and implemented within 7 days of the comprehensive assessment and prepared, reviewed, and revised by a team of health professionals for two residents. For one resident, the record showed admission on 04/22/2024 and a readmission with diagnoses including subsequent encounter for closed fracture with routine healing, personal history of TIA/stroke, cerebral infarction without residual deficits, and difficulty walking. The admission MDS dated 04/25/2024 showed a BIMS score of 4 out of 15, indicating the resident was not cognitively intact. However, the record contained no documented evidence of a resident-specific comprehensive care plan, and the existing care plan included interventions such as encouraging the resident not to yell at other residents and to voice feelings, despite the resident being assessed as cognitively impaired. The record also showed the care plan was not updated quarterly. For the second resident, the record showed admission on 10/29/2024 for short-term rehabilitation following an ischemic stroke. The record contained no documented evidence that a personalized comprehensive care plan was developed and revised. The facility developed a goal for the resident to return home, although the resident had been homeless before admission. The MDS Coordinator stated the goal should have been tailored to the resident and should have said return to community instead of return to home. The record also showed the care plan was not updated quarterly. During interviews, the MDS Coordinator stated she was responsible for implementing and updating care plans, the DON stated each resident should have a person-centered comprehensive care plan, and the Administrator stated she expected all residents to have comprehensive care plans that were reviewed and revised quarterly at minimum.
Infection Control and PPE Failures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for four sampled residents, including residents on Enhanced Barrier Precautions (EBP) and residents using nebulizer equipment. For one resident with a physician order for EBP related to a history of MRSA in a wound, a CNA was observed providing care without donning PPE first and then leaving the room without washing or sanitizing hands. The resident’s room had an EBP sign on the door and a cart with gloves and disposable gowns at the entrance. During interview, the CNA stated that residents on EBP should not be touched unless staff were wearing gloves and a disposable gown, and acknowledged that she should have performed hand hygiene after exiting the room. Three other residents had nebulizer equipment observed outside of proper storage when not in use. One resident had nebulizer tubing laying on an overbed table, another had tubing touching the floor with the nebulizer kit laying on the floor, and two additional residents had nebulizer kits sitting on furniture in their rooms without being stored in a bag. The facility’s policy stated nebulizer tubing should be kept in a sealed bag when not in use. Interviews with the RN, Infection Preventionist, and Administrator confirmed expectations that staff follow infection control policies, use appropriate PPE for EBP, perform hand hygiene after care, and store nebulizer tubing in a bag when not in use.
Failure to Properly Identify Resident Leads to Significant Medication Error
Penalty
Summary
A significant medication error occurred when a registered nurse (RN) administered medications intended for one resident to another due to a failure to properly identify the correct resident. The incident took place after two residents decided to switch bed positions, and the facility did not update the bed assignments in the computer system until the following day. As a result, the RN relied solely on room numbers rather than verifying the resident's picture, name, and date of birth, leading to the administration of multiple medications—including insulin, Xanax, atorvastatin, donepezil, duloxetine, Eliquis, acetaminophen, ropinirole, simethicone, and trazodone—to the wrong resident. The RN involved stated that it was his first shift working independently and acknowledged not following proper resident identification protocols, despite having received training. The facility's policies required correct resident identification and medication administration, but these were not followed during the incident. Interviews with facility leadership confirmed awareness of the event and the expectation that residents be properly identified before medication administration. The resident who received the incorrect medications was assessed and found to be in no distress at the time.
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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.
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Nursing homes near Stanford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Landmark Of Lancaster Rehabilitation And Nursing C | 7.4 mi | ★★★★★ | 4 | 0 |
| Henson Park Health & Rehabilitation | 8.8 mi | ★★★★★ | 0 | 0 |
| Danville Centre For Health & Rehabilitation | 9.8 mi | ★★★★★ | 4 | 0 |
| Rockcastle Health & Rehabilitation Center | 16.5 mi | ★★★★★ | 12 | 0 |
| Harrodsburg Health & Rehabilitation Center | 18.4 mi | ★★★★★ | 4 | 0 |
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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 July 2026) and official state health department websites.