Stanford Court Skilled Nursing & Rehab Center

Inspectors wroteBased on interview and record review the facility failed to provide necessary wound treatment and services in accordance with professional standards of practice by failing to obtain, implement, and provide evidence of physician ordered surgical wound care treatment for one of three residents (Resident 1). These deficient practices placed Resident 1 at risk for worsening of the surgical wound, infection, pain, delayed healing, and further health complications that could result in negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure written information related to advance directive was provided to 6 of 10 sampled residents (1,12,45, 85, 130, and 144). This failure may affect Resident 1,12, 45, 85, 130, and 144's decision to formulate an advance directive due to lack of knowledge and information. FindingsOn 12/3/25 a review of Resident 1's clinical record was conducted. Resident 1 was admitted to the facility on [DATE] per the facility's admission Record. The facility's document titled Advance Directive Acknowledgement dated 10/16/25, indicated, [ ] I have received the brochure on Advance Directives was left blank. There was no documentation that the facility provided Resident 1 with Advance Directive information. On 12/3/25 a review of Resident 12's clinical record was conducted. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the water temperature in nine residents' rooms (Resident 134, 135, 140, 123, 128, 132, 113, 53, and 147) and the shower room located by the 500 rooms was below 120 degrees Fahrenheit ( F). As a result of this deficient practice, there was the potential for residents using the water to get scalded.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper pharmaceutical services for three of three residents (Residents 45, 134, 146) when: 1. The administration of busPIRONE (anti-anxiety medication that is primarily used to treat general anxiety disorder) was 3 hours and 55 minutes late for one resident (Resident 45).2. There were delays in the MAR documentation after controlled medications were removed from the locked storage for two of two randomly selected residents (Resident 134 and 146). As a result, it could not be determined what time the medications were administered to Residents 45, 134, and 146.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 133) was free from unnecessary medications when licensed nurses (LN) did not follow the physician orders while administering laxatives (medication that promotes bowel movements) nine times. As a result of this deficient practice, Resident 133 experienced several episodes of diarrhea. Cross Reference: F726Findings: A review of Resident 133's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of surgical aftercare following surgery on the nervous system. On 12/2/2025 at 8:50 A.M., an observation and interview was conducted with Resident 133 while inside his room. Resident 133 was observed with a nasal gastric tube ( NG-tube a thin, soft tube that goes in through the nose, into the stomach, used to give food and medications). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure practices that mitigated the risk of resident food contamination were followed when:1. The dietary manager (DM) did not wear a beard guard while in the kitchen and overseeing the breakfast tray line.2. [NAME] 1 used a broken thermometer to take final food temperatures prior to serving. In addition, staff did not take final food temperatures consistently before the food was placed on the tray line and then served to residents. These deficient practices had the potential to cause foodborne illnesses.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to implement interventions for one of seven residents (Resident 16) written care plan (detailed plan with information about a resident's treatment, goal, and interventions) for activities of daily living related to nail care. This failure had the potential for the resident to not receive care and services specific to the residents' needs. FindingsA review of Resident 16's admission record indicated the resident was admitted on [DATE] with diagnoses which included unspecified fracture of the fifth lumbar vertebra, need for assistance with personal care, and abnormalities of gait and mobility. On 12/1/25 at 8:35 A.M., an observation and interview was conducted with Resident 16 in Resident 16's room. Resident 16 was lying in bed, watching tv. The resident's fingernails were observed to be long, approx. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide the necessary nail care to maintain good grooming and personal hygiene for one of seven residents (Resident 16). This failure resulted in Resident 16 having long, yellowing, discolored fingernails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure six of six licensed nurses (LN 11, LN 21, LN 22, LN 23, LN 24 and LN 25) staff were competent when assessing bowel eliminations and administering laxatives. As a result, there was the potential for residents to be given unnecessary laxatives (promotes bowel movements) which may lead to diarrhea, weight loss, skin breakdown and dehydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one medication cart was locked when unattended. This failure had the potential for residents and unauthorized staff to have access to the medications in the medication cart.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two kitchen staff (Cook 1 and cook assistant [CA]) were competent in taking final food temperatures and proper use of the thermometer. As a result of these deficient practices, there was the potential for residents' food to have been contaminated and unsafe to consume.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu during lunch service. This deficient practice had the potential for residents to not be satisfied with the food which may lead to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate infection prevention and control practices when a nurse did not clean the blood pressure cuff in between resident uses for three of three residents (Resident 20, 85, and 132). In addition, the facility failed to properly clean and disinfect a Purewick device (an external urinary catheter) according to the manufacturer's guidelines for one resident (Resident 124). As a result of these deficient practices, the residents were placed at risk for contracting infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure current infection control practices were followed when the facility did not designate dedicated vital signs (VS) equipment (blood pressure cuff, stethoscope and thermometer) for two of two residents with clostridium difficile (C. diff- highly contagious bacteria in the large intestine causing diarrhea) infection reviewed for infection control. (Resident 1 and 4) This failure had the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure current infection control practices were followed for two of five residents reviewed for infection control when: 1. Staff wore an N-95 (a fitted filtering mask) mask over a surgical mask, 2. Staff did not use a face shield upon entrance into a room with COVID-19 (a very contagious respiratory virus). This failure resulted in staff being exposed to COVID-19 and had the potential to spread infection to all residents residing in the facility. 1. Resident 1 was admitted to the facility on [DATE] according to the facility's admission Record. The change in condition progress note for Resident 1 dated 2/3/25 at 4:08 P.M. indicated, .Covid tested via rapid test with positive result . An observation of Resident 1's room on 2/6/25 at 9:02 A.M. was conducted. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a resident-centered care plan for one of five residents (Resident 2) reviewed for care plan development. Resident 2 was identified to be at high risk for fall which was not reflected in the resident ' s care plan. This failure had the potential for staff to not be aware of Resident 2 ' s fall risk, which could potentially result in staff not providing the appropriate fall intervention to prevent fall incidents.

Inspectors wroteBased on interview and record review, the facility failed to revise one of five residents ' (Resident 3) care plan related to fall risk. This failure resulted in the miscommunication of Resident 3 ' s fall risk among the healthcare provider, which could potentially result in fall incidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of five residents (Resident 21) was free from future falls when the facility failed to conduct a thorough investigation of Resident 21 ' s fall. This failure has the potential to cause a fall with injury to Resident 21 as the facility was not able to determine the cause of Resident 21 ' s fall and implement specific interventions to prevent future falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food served to all residents was in a palatable, flavorful manner that maintained the nutritional value of the menu items served. This failure had the potential to decrease residents' meal intake and contribute to weight loss. The facility census was 90.

Inspectors wroteBased on observation, interview and record review the facility did not maintain or perform the sanitary (free of bacteria and other germs that is can be hazardous to humans) practices according to their policies and procedures of using a low-temperature dishwasher. This failure had the potential to cause widespread food borne illness among all 90 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents reviewed for dignity was provided care in a manner that promoted dignity and respect when resident was instructed to urinate (to excrete urine) on the diaper (Resident 178). As a result, the residents' self-esteem and self-worth was devalued.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a homelike environment was provided for three out of 23 (14, 22,24) sampled residents, when resident's walls were not repaired after damaged by residents' beds. This deficient practice created an environment that was not homelike for three residents.

Inspectors wroteBased on interview and record review, the facility failed to re-evaluate one of three residents (Resident 23) reviewed for Pre-admission Screening and Resident Review (PASARR- a federal requirement to prevent individuals with mental illness [MI], developmental disability [DD], intellectual disability [ID], or related conditions from being inappropriately placed in nursing homes for long term care). This failure had the potential for Resident 23 to not receive necessary mental health care services in an appropriate healthcare setting.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services which met professional standards of practice for one of 23 sampled residents (Resident 47) when: 1. Resident 47 was using a left-hand splint (a device to help immobilize and prevent contractures) without a Medical Doctor's (MD) order. 2. Resident 47 did not have an MD order for triamcinolone ointment (a prescribed skin cream to treat skin associated irritation such as rash) and left open at Resident 47's nightstand table. Cross Reference F761 and F813 This failure had the potential for Resident 47 to suffer complications for an unmonitored left hand splint and potential for anaphylactic (life threatening allergy) reactions from triamcinolone side effects.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide the necessary care to maintain good grooming and personal hygiene for one of four residents (Resident 15) reviewed requiring dependent (helper does ALL the effort. Resident does none of the effort to complete the activity) assistance. This failure resulted to Resident 15 having long, and dirty fingernails.

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure that a resident received needed care and services in accordance with professional standards of practice for one out of four residents reviewed requiring dependent (helper does all the effort. Resident does none of the effort to complete the activity) assistance. This failure had the potential to compromise Resident 15's health status.

Inspectors wroteBased on observation, interview, and record review the facility failed to appropriately care for one of three residents' drainage tube reviewed for staff competency (Resident 177). This deficient practice had the potential for unresolved infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to store medications in a secured location for two of three residents (Resident 47 and Resident 30) reviewed for medication storage when: 1. A discontinued order for triamcinolone ointment (a prescribed skin cream to treat skin associated irritation such as rash) was kept uncapped and unsecured on Resident 47's nightstand table. Cross Reference F658 and F813 2. A prescribed Salonpas (pain patches) was kept at Resident 30's bedside table. These failures had the potential for medication misuse, effectiveness and/or severe allergic complications.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to store foods in a safe and sanitary manner according to their facility's policies and procedure for outside foods brought by family and visitors for two out of seven residents (Resident 59 and Resident 47) reviewed for food preference and homelike environment when: 1. Resident 59 had a bag of unlabeled apples and oranges placed at the bedside for a week or more. Cross reference F880 2. Resident 47 had three unlabeled food items with a brownish yellow banana, placed on top of a cluttered emesis basin, plastic wrapped chocolate pastries on top of a plastic container and a sandwich in an open plastic container unsecured without a lid at the bedside. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a neutropenic (low white blood cell count- part of the body's immune system) precautions room for one reviewed resident (Resident 58), was free of potential infection from raw foods. This failure had the potential outcome of endangering Resident 58's health condition and possible decline from exposed raw foods.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff reported in a timely manner an allegation of abuse to the facility's administration including the California Department of Public Health (CDPH- the State Survey and Certification Agency) for one resident (Resident 1) This deficient practice had the potential for a repeat abuse allegation for Resident 1, and for all other residents to be unprotected from abuse. Resident 1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood) according to the facility's admission Record. The admission MDS (a clinical assessment tool) dated 5/16/24, listed a cognitive score of 7, indicating Resident 1 was severely impaired. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure four of four sampled residents (Residents 10, 13, 48, 169) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications including Seroquel (an antipsychotic medication for bipolar disorder, depression, and schizophrenia) and Nuplazid (an antipsychotic medication for Parkinson disease psychosis) when: 1. Resident 10 was administered Seroquel without an appropriate indication and/or clinical justification, no resident-centered behavioral interventions were implemented prior to initiation and during use of Seroquel, inadequate behavioral monitoring was documented during use of Seroquel, and manufacturer specified monitoring were not done during use of Seroquel; 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure kitchen staff performed their tasks safely and correctly when: 1. a Dishwasher Diet Aide (DA 1) could not correctly test the sanitizer solution (liquid that removes bacteria) on dishes used for resident meals, 2. a [NAME] (CK) did not know the correct cool down procedure timeframe for cooked meats. As a result, 61 residents who consumed food from the kitchen had the potential to be exposed to bacterial contamination through unsafe meat or unsanitary dishes. Facility Census was 65.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe and sanitary environment that lessened the risk for foodborne illness and cross contamination when: 1. the dish machine sanitation cycle failed to sanitize dishes at the correct sanitizing level, according to facility policy and standards of practice; 2. five cucumbers with a visible substance resembling white mold and multiple dark brown spots were stored and comingled with other cucumbers and vegetables in the walk-in refrigerator; 3. a plastic container of rice and of flour were not labeled or dated with a use by date; and a plastic container of powdered sugar had an expired use by date; and 4. an ice machine chute (a channel which allows things to slide or pass) displayed a dark brown film build up and black spots around the rim. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment in accordance with the facility's policy and procedure when one of 16 sampled residents (Resident 7) was not properly positioned in the semi-Fowler's position (defined as a body position at 30 degrees head-of-bed elevation) during the administration of medications via a G-Tube (gastrostomy tube, a tube inserted through the belly that brings nutrition or medications directly to the stomach). This failure had the potential for not meeting Resident 7's therapeutic needs and had the potential of causing aspiration (breathing in medication or fluid into the lungs), which could lead to serious lung problems such as pneumonia (lung infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when observation of 30 opportunities during the medication pass resulted in six errors. The calculated medication error rate was 20 percent. These failures placed Residents 7, 40, 43, and 46 at risk for not receiving the full therapeutic effects of medications when medications were not given according to the physician's orders and/or the manufacturer's specifications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications had proper storage and labeling when: 1. Medication Cart 100 was left unlocked during medication pass; 2. Medication Cart 200 was left unlocked during medication pass; 3. For Resident 46, an expired insulin (medication for diabetes) vial was found in medication cart 100. These failures had the potential for lost, left, misuse or abuse of medications for two out of four medication carts; and unsafe and ineffective use of medications with decreased therapeutic effectiveness when used past the expiration date for one out of 16 sampled residents (Resident 46).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an infection control procedures when: 1. Registered Nurse 2 (RN 2) failed to observe infection control measures by failing to properly disinfect resident's glucometer for one of 3 randomly selected residents (Resident 35) according to manufacturer's specifications; 2. Licensed Nurse 1 (LN 1) failed to observe infection control measures by failing to properly disinfect resident's glucometer for two of 3 randomly selected residents (Resident 46 and 170) according to manufacturer's specifications. These failures had the potential for the development and the spread of infection to 3 of 3 randomly selected residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one residents reviewed for communication received services to accommodate his needs and preferences (35). This failure resulted in Resident 35 experiencing frustration when trying to communicate.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the choice to wake up late for one of one residents reviewed for choices (369) . This failure had the potential for psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure a pressure ulcer (PU, an injury to the skin and underlying tissue resulting from pressure) was coded correctly in the MDS, (an assessment tool) for one of two residents reviewed for PU (14). This failure had the potential for incorrect information being sent to Centers for Medicare and Medicaid (CMS, the organization responsible for creating health and safety guidelines for healthcare facilities).

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement residents' care plans related to: 1. Toileting for one of one residents reviewed for bowel and bladder (369) 2. Refusal of vaccinations for two of five residents reviewed for vaccinations (57 and 169). These failures had the potential to not meet the goals of treatment and needs of Residents 369, 57 and 169.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician's order for a referral to a endocrinologist (Endo, a doctor who specializes in diabetes [a long-term condition that impacts the way the body processes blood sugar] management) was carried out for one of 16 sampled residents with diabetes (35). This failure resulted in Resident 35 having elevated blood sugars for an extended period of time, and increased the potential for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one residents reviewed for bowel and bladder was scheduled for toileting program per the resident's care plan (369). This failure had the potential for Resident 369 to develop skin breakdown and urinary tract infection (UTI).

Inspectors wroteBased on interview and record review, the facility failed to identify and develop an effective QAPI (Quality Assurance and Performance Improvement) plan. This failure had the potential to affect the care provided to the residents. Cross reference: