Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Stanley Total Living Center during CMS and state inspections, most recent first.
Surveyors observed that three residents receiving oxygen therapy did not have cautionary or safety signage posted outside their rooms to indicate oxygen was in use. Despite physician orders and active administration of oxygen, staff and leadership confirmed that the facility's policy was not to post such signs at resident rooms, relying instead on no smoking signs at facility entrances and exits.
A nurse failed to properly disinfect a shared glucometer between uses on two residents, posing a risk of bloodborne pathogen exposure. Despite having attended various training sessions, the nurse was unable to recall the correct disinfection procedure and had not attended the recent skills fair. The facility's training and competency assessments were insufficient to ensure the nurse's compliance with infection control practices.
A facility failed to disinfect a shared glucometer between two residents according to policy, using an alcohol prep pad instead of the required disinfectant wipe. Nurse #1 did not follow the correct procedure, risking cross-contamination. The issue was identified during a survey, highlighting a gap in adherence to infection control protocols.
A resident with impaired cognition fell and injured her head due to a failure to implement fall prevention measures. The resident's care plan required the bed to be in a low position and a fall mat to be placed beside it, but these were not in place. A newly trained CNA left the resident unattended in a high bed position without a fall mat, resulting in the fall.
A resident admitted with a right femur neck fracture was prescribed Enoxaparin Sodium Injection, but the facility failed to include anticoagulant therapy in the care plan. Despite daily administration of the medication, staff interviews revealed a lack of awareness and communication regarding the need for specific care planning. The MDS Nurse, NP, and other staff acknowledged monitoring requirements, but the care plan did not reflect these interventions, indicating a gap in the facility's care planning process.
Two residents on anticoagulants did not have person-centered care plans that included necessary goals and interventions for monitoring therapy. Despite receiving blood thinners, their care plans lacked specific monitoring for complications like bruising and bleeding. Staff interviews revealed a lack of awareness about the need for specific care plans for anticoagulant therapy.
A resident with anxiety and dementia was prescribed busPIRone HCl on a PRN basis without a 14-day stop date, contrary to facility policy. The medication was administered only once, and staff interviews revealed a lack of awareness and oversight regarding the absence of a stop date. The NP and nurses acknowledged the oversight during the medication reconciliation process.
Failure to Post Oxygen in Use Signage Outside Resident Rooms
Penalty
Summary
Surveyors found that the facility failed to post cautionary and safety signage outside the rooms of three residents who were receiving oxygen therapy. Each of these residents had physician orders for oxygen administration due to chronic or acute respiratory failure with hypoxia, and observations confirmed that oxygen was actively being administered via nasal cannula during multiple surveyor visits. Despite this, there were no signs posted at the entrances to these residents' rooms to indicate that oxygen was in use. Interviews with facility staff, including a nursing assistant, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator, revealed that the facility did not have a practice of posting oxygen in use signage at individual resident rooms. The DON and Administrator stated that because the facility was non-smoking and had no smoking signs posted at entrances and exits, they believed it was not necessary to post oxygen in use signs at resident rooms. This practice was confirmed by staff and observed by surveyors during their visits.
Failure to Disinfect Shared Glucometer
Penalty
Summary
The facility failed to ensure that a nurse demonstrated competency in cleaning and disinfecting a shared glucometer according to the manufacturer's recommendations and the facility's policy. Nurse #1 was observed using a shared glucometer on Resident #28 and then on Resident #7 without properly disinfecting it in between uses. This failure to follow proper disinfection procedures posed a high likelihood of exposing residents to bloodborne pathogens. Nurse #1's training records indicated that she had attended various educational sessions related to infection prevention and glucometer disinfection. However, during an interview, Nurse #1 was unable to recall the correct procedure for disinfecting the glucometer and incorrectly believed that alcohol or alcohol-based hand sanitizer could be used for disinfection. She had not attended the recent skills fair that included training on glucometer disinfection, which was part of the facility's annual competency assessment. The facility's Staff Development Coordinator and Director of Nursing confirmed that education on glucometer disinfection was provided during new hire orientation and annually. Despite this, Nurse #1 did not demonstrate the required competency, and the facility was unable to explain why she did not know the correct procedure. The deficiency affected one of the three residents who required blood glucose level checks, highlighting a gap in ensuring that all nursing staff were adequately trained and competent in infection control practices.
Removal Plan
- Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
- Provide education/competency to other licensed nurses who had not completed the most recent training on disinfecting shared blood glucose meters.
- Terminate Nurse #1 from employment to ensure no other residents on her assigned unit have the potential of being affected by continued deficient practice.
- Provide training/education both in person and via Zoom meeting for all licensed nursing staff on the Diabetes Management Policy and Procedures for properly cleaning and disinfecting shared blood glucose meters.
- Include validation of competency, either in-person or through verbally providing the appropriate steps of the procedure.
- Ensure no current licensed nurse will be allowed to work prior to receiving this education.
- Include this training in the new hire orientation provided by the Staff Development Coordinator.
- Ensure the education and competency of every licensed nurse regarding the proper cleaning and disinfecting of a multi-use blood glucose meter will be reviewed and verified via a skills fair.
- Ensure any licensed nurse who does not attend the mandatory competency assessment will not be allowed to work until this has been completed.
Failure to Properly Disinfect Shared Glucometer
Penalty
Summary
The facility failed to properly disinfect a shared glucometer between two residents, Resident #28 and Resident #7, according to the facility's policy and the manufacturer's user guide. The incident occurred when Nurse #1 used an alcohol prep pad instead of the required EPA-approved disinfectant wipe to clean the glucometer after checking Resident #28's blood glucose level. This practice was not in line with the facility's policy, which mandates the use of a specific disinfectant wipe to clean and disinfect the glucometer thoroughly, ensuring it remains wet for two minutes before air drying. During the observation, Nurse #1 was seen using an alcohol prep pad to clean only the area around the test strip insertion site of the glucometer, both before and after use. This incorrect method was used again when preparing to check Resident #7's blood glucose level, at which point the surveyor intervened. Nurse #1 admitted to using the alcohol prep pad because she believed it was appropriate, demonstrating a lack of understanding of the correct disinfection procedure. Interviews with the Risk Management Nurse, Infection Preventionist, and Director of Nursing confirmed that the glucometer should be disinfected before and after each use with the specified disinfectant wipe to prevent the transmission of bloodborne pathogens. The facility's policy was not followed, and Nurse #1 was unable to articulate the correct disinfection process, indicating a gap in training or adherence to established protocols.
Removal Plan
- The current policy and procedures for Diabetes Management was reviewed by the Director of Nursing, ADON/Case Management Coordinator, Staff Development Coordinator, Infection Control Preventionist, and Administrator to ensure accuracy of procedures following manufacturer's directions.
- Training/education was provided to all licensed nursing staff on the Diabetes Management Policy and Procedures for properly cleaning and disinfecting shared blood glucose meters before and after each use.
- No current licensed nurse will be allowed to work prior to receiving this education.
- This training will be included in the new hire orientation training.
- The MD/Medical Director and Nurse Practitioner were both verbally notified of the breach.
- The Gaston County Health Department was notified via email of the breach.
- The Responsible Party of resident #28 was notified of the breach.
- The Administrator and Director of Nursing are responsible for the implementation and completion of the removal plan.
Failure to Implement Fall Prevention Measures Leads to Resident Injury
Penalty
Summary
The facility failed to provide care in a safe manner, resulting in a resident falling from her bed and sustaining a head injury. The resident, who had severely impaired cognition and required total assistance with bed mobility and transfers, was found on the floor with a laceration to her scalp. The care plan for the resident included keeping the bed in a low position and placing a fall mat beside the bed, but these interventions were not in place at the time of the fall. The incident occurred when a newly trained nurse aide, who was unaware of the resident's fall risk, left the resident unattended in a high bed position without a fall mat. The aide had left the room to find assistance for transferring the resident to a wheelchair for dinner. Upon returning, the aide found the resident on the floor, indicating that the care plan interventions were not followed. Interviews with staff revealed that the bed was in a high position and the fall mat was not in place, which were critical factors in the resident's fall. The facility's investigation determined that the nurse aide responsible for the resident's care did not implement the necessary fall prevention measures, leading to the resident's injury.
Failure to Include Anticoagulant Therapy in Resident Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan addressing anticoagulant therapy for a resident admitted with a right femur neck fracture. The resident was prescribed Enoxaparin Sodium Injection, a blood thinner, to be administered daily. Despite the resident's cognitive intactness and the presence of an admission order for the anticoagulant, the care plan dated 10/1/24 did not include specific goals and interventions for anticoagulant therapy. This omission was identified during a review of the resident's Medication Administration Record, which confirmed the daily administration of the anticoagulant from 10/2/24 to 10/22/24. Interviews with facility staff revealed a lack of awareness and communication regarding the inclusion of anticoagulant therapy in the care plan. The MDS Nurse indicated that anticoagulant therapy was typically noted under skin monitoring for abnormal bruising, but it was not specifically care planned. The NP and other nursing staff acknowledged the need to monitor for signs of bleeding, bruising, and hematuria, yet there was no clear documentation in the care plan. The Director of Nursing and the Administrator were unaware that a specific care plan was required for anticoagulant therapy, assuming that nurses would inherently know what to monitor. This oversight highlights a gap in the facility's care planning process for residents on anticoagulant therapy.
Failure to Implement Anticoagulant Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for residents on anticoagulants, specifically for two residents. Resident #19, who was admitted with a right hip fracture and had a history of gastrointestinal bleeding, was prescribed Enoxaparin Sodium as a blood thinner post-surgery. However, the care plan did not include specific goals and interventions for anticoagulant therapy. Despite receiving the medication daily, the care plan lacked monitoring for potential complications such as bruising, hematuria, and bleeding, which were noted as necessary by the NP and other staff during interviews. Similarly, Resident #34, diagnosed with paroxysmal atrial fibrillation, was on Apixaban, another anticoagulant, but their care plan also failed to include necessary goals and interventions for monitoring anticoagulant therapy. Interviews with the MDS Nurse, NP, and other staff revealed a lack of awareness and understanding of the need for specific care plans for residents on anticoagulants. The Director of Nursing and the Administrator were unaware that such specific care plans were required, assuming that nurses would inherently know what to monitor.
Failure to Limit PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to limit the duration of a psychotropic medication ordered on an as-needed (PRN) basis to 14 days for a resident diagnosed with generalized anxiety disorder and unspecified dementia with anxiety and mood disturbance. The resident was admitted with an order for busPIRone HCl, a psychotropic medication, to be given as needed for anxiety, but the order did not include a stop date. The resident's care plan included administering psychotropic medications as ordered and monitoring for side effects and effectiveness, but the electronic Medication Administration Record (eMAR) showed the resident received the medication only once in October, with no doses recorded in August or September. Interviews with facility staff, including the Nurse Practitioner (NP), two nurses, the Director of Nursing (DON), and the Administrator, revealed a lack of awareness and oversight regarding the absence of a stop date for the PRN order. The NP and nurses acknowledged that PRN psychotropic orders should be written for 14 days and reviewed for effectiveness before being rewritten. The NP admitted the oversight during the medication reconciliation process upon the resident's admission, and the DON and Administrator were unaware of the issue until it was brought to their attention.
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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 Stanley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Greens At Gastonia | 6.1 mi | ★★★★★ | 2 | 0 |
| Peak Resources - Gastonia | 6.2 mi | ★★★★★ | 2 | 0 |
| Gastonia Health & Rehab Center | 6.2 mi | ★★★★★ | 4 | 0 |
| Courtland Terrace | 6.7 mi | ★★★★★ | 4 | 0 |
| Juniper Gardens Center For Nursing And Rehabilitat | 6.9 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.