Deficiency Records for Stanford Court Skilled Nursing and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Stanford Court Skilled Nursing and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| 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 | 2023-09-18 | 2023-09-27 | 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 | 2023-01-12 | 2023-04-24 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-01-12 | 2023-04-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-12 | 2023-04-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-12 | 2023-03-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-01-12 | 2023-03-23 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-01-12 | 2023-03-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-12 | 2023-03-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-12 | 2023-03-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-12 | 2023-03-23 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-12 | 2023-03-23 | 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 | 2023-01-12 | 2023-03-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-12 | 2023-03-23 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-01-12 | 2023-03-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-12 | 2023-03-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-18 | 2023-01-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-18 | 2023-01-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-18 | 2023-01-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-18 | 2023-01-27 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-05 | 2022-10-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-12 | 2022-04-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-05 | 2021-08-20 | Y |
| Provide primary/alternate means for communication. | Fire Safety | 2019-08-29 | 2019-09-12 | N |
| Use approved construction type or materials. | Fire Safety | 2019-08-29 | 2019-09-12 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-08-29 | 2019-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-29 | 2019-09-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-29 | 2019-09-12 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2019-08-29 | 2019-09-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-09 | 2019-09-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-08-09 | 2019-09-06 | 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 | 2019-08-09 | 2019-09-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-09 | 2019-09-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-09 | 2019-09-06 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-08-09 | 2019-09-06 | 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 | 2019-08-09 | 2019-09-06 | 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 | 2019-08-09 | 2019-09-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-08-09 | 2019-09-06 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-08-09 | 2019-09-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-08-09 | 2019-09-06 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-09-28 | 2018-10-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-09-28 | 2018-10-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-09-28 | 2018-10-16 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-07-13 | 2018-08-24 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-07-13 | 2018-08-24 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-07-13 | 2018-08-24 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-07-13 | 2018-08-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-13 | 2018-08-24 | 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 | 2018-07-13 | 2018-08-24 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-07-13 | 2018-08-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-07-13 | 2018-08-24 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-07-13 | 2018-08-24 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-07-13 | 2018-08-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-13 | 2018-08-24 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-07-13 | 2018-08-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-13 | 2018-08-24 | N |
