A list of the most recent deficiencies for Stanford Care and Rehab, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-07 | 2023-07-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-07 | 2023-07-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-10 | 2023-07-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-10 | 2023-07-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-10 | 2023-07-20 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-06-10 | 2023-07-20 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-06-10 | 2023-07-20 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-06-10 | 2023-07-20 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-06-10 | 2023-07-20 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-06-10 | 2023-07-20 | Y |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2023-06-10 | 2023-07-20 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-06-10 | 2023-07-20 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-07 | 2023-07-01 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-07-09 | 2021-07-27 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-07-09 | 2021-07-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-07-09 | 2021-07-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-09 | 2021-07-27 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-07 | 2021-07-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-23 | 2021-05-20 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2020-02-17 | 2020-09-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-17 | 2020-09-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-05 | 2020-04-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-03-05 | 2020-03-30 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-03-05 | 2020-03-30 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-03-05 | 2020-03-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-03-05 | 2020-03-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-03-05 | 2020-03-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-05 | 2020-03-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-03-05 | 2020-03-30 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-03-05 | 2020-03-30 | N |
| Post nurse staffing information every day. | Health | 2020-03-05 | 2020-03-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-03-05 | 2020-03-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-03-05 | 2020-03-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-03-05 | 2020-03-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-05 | 2020-03-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-05 | 2020-03-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-17 | 2020-03-30 | N |
