Stanford Crossing

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to immediately inform the resident's physician and the resident's representative when there was a significant change in the resident's physical and mental status for one (1) of 51 total sampled residents, Resident (R) 19. The facility assessed R19 to have decreased meal and fluid intake on [DATE] through [DATE]. Per interview, R19 also had a change in level of consciousness on [DATE] and [DATE]. However, there was no documented evidence the staff notified the resident's physician or representative from [DATE] through [DATE] of the resident's changes. R19 expired on [DATE]. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan and failed to implement care plan interventions. Additionally, the facility failed to identify, assess, and intervene for an acute change in the resident's condition related to decreased appetite and level of consciousness for one (1) of 51 sampled residents, Resident (R) 19. The facility assessed R19 to have decreased meal and fluid intake on 11/24/2025 through 11/27/2025. Per interview, R19 also had a change in level of consciousness on 11/26/2025 and 11/27/2025. However, there was no evidence the staff completed a thorough nursing assessment from 11/24/2025 through 11/27/2025. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, it was determined the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for one (1) of 51 total sampled residents, Resident (R) 19. The facility failed to document assessments for R19 from 11/24/2025 to 11/27/2025 when R19 had a decline in intake and level of consciousness. R19 was transferred to the hospital on [DATE]. R19 expired on 12/04/2025.

Inspectors wroteNumber of residents sampled:11Number of residents cited: 7 Based on observations, interviews, record review, review of facility staffing documentation, and review of the facility's Payroll Based Journal (PBJ) report, the facility failed to ensure it had an effective system to provide sufficient numbers of qualified nursing staff to meet the needs of 6 of 51 sampled residents (Resident (R) 8, 18, 30, 68, 94 and 117).

Inspectors wroteBased on observation, interview, and facility policy review the facility failed to provide housekeeping services to ensure a clean and sanitary environment for eight of 51 sampled residents (R) Residents ((R) 6, R7, R64, R37, R58, R70, R72, and R92).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure a care plan was developed and implemented for two of 51 sampled residents (Resident (R5 and R90).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (4) of 51 sampled residents (Resident (R)7, R28, R42 and R50).

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to provide safe medication administration for one of 12 sampled residents.

Inspectors wroteBased on observation, interview, record review, facility document and policy review, it was determined the facility failed to ensure residents' comprehensive care plans were developed and implemented for one (1) of six (6) sampled residents (Resident #7). The facility assessed Resident #7 to be a risk for elopement and care planned him/her for the risk with interventions which included: to distract from wandering by being offered pleasant diversions which included: structured activities, food, conversation, television, or a book. On 05/16/2023, the resident was observed to push on the exit door handle and press the door code box to exit the facility. The resident was provided a Wandergaurd at that time; however, the resident's person-centered care plan failed to address the resident pressing the code box and/or provide increased supervision or monitoring for the safety of the resident. [...]

Inspectors wroteBased on observation, interview, record review, review of facility documents and policy, it was determined the facility failed to provide effective monitoring and supervision to prevent elopement for one (1) of six (6) sampled residents assessed as an elopement risk (Resident #7). The facility assessed Resident #7 as at risk for elopement and care planned the resident to be distracted from wandering by being offered pleasant diversions, structured activities, food, conversation, television, or a book. However, the resident was able to exit the facility undetected by staff on 07/15/2023 at 6:40 PM, based on a review of the facility's Final Investigation Report. The resident was found located outside the building unsupervised for approximately five (5) minutes. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure its pharmaceutical services, to include procedures which assured the accurate acquiring and receiving of all controlled drugs, implemented its policy to prevent diversion for one (1) of thirty-five (35) sampled residents (Resident #49). Resident #49 was found to have missing controlled substance medications which could not be accounted for, and the facility was unable to locate them.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop and/or implement a person-centered Comprehensive Care Plan (CCP) which included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for six (6) of forty-seven (47) sampled residents (Residents #1, #16, #17, #18, #19 and #88). 1. Review of Resident #1's CCP revealed the facility assessed Resident #1 as a fall risk, on 05/29/2018, with a history of impaired cognition and restless/anxious behaviors, balance problems of which resident required extensive assistance with bed mobility, transfers, and toileting. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision and assistive devices to prevent accidents or hazards. In addition, the facility failed to conduct a thorough fall investigation that led to a root cause determination; along with the development and implementation of an action plan after each fall for five (5) of forty-seven (47) sampled residents (Residents #1, #16, #17, #18 and #19). 1. On [DATE], Resident #1 was ordered an air mattress (alternating pressure system) for his/her comfort, without assessing the resident's needs and safety for the device. [...]

Inspectors wroteBased on interview, record review, review of the facility's policy, and review of the facility's Administrator's Job Description, it was determined the facility failed to be administered in a manner which enabled its effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility was cited at the S/S of Immediate Jeopardy during the 06/10/2023 survey. Review of the 02/10/2020 Recertification Survey's Plan of Correction (POC), and the Abbreviated Survey's POC revealed the facility was previously cited at actual harm and Immediate Jeopardy (IJ). The 06/10/2023 survey had repeat deficiencies that had been cited on the 02/10/2020 survey. Review of the fall tracker revealed the facility had a total of one-hundred and eight (108) falls within a four (4) month time period. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure its Governing Body was actively engaged in ensuring its policies were effectively implemented regarding the management and operation of the facility. The facility's Governing Body failed to ensure the facility sustained substantial compliance in the areas of 42 CFR 483.21 Develop/Implement Comprehensive Care Plan, F656; 42 CFR 483.25 Quality of Care, Free from Accidents/Hazards/Supervision/Devices, F689; 42 CFR 483.70 Administration, (F835); 42 CFR 483.75 Quality Assurance and Performance Improvement (QAPI), F865; 42 CFR 483.70 Governing Body, F837; and 42 CFR 483.70 Medical Director, F841. [...]

Inspectors wroteBased on interview and record review, it was determined the facility failed to have an effective system in place to investigate the root cause of the resident's falls. The Medical Director was responsible for providing the staff direction related to the facility's policy and the current professional standard of practice and failed to ensure the coordination of medical care in the facility. As a result, five (5) of forty-seven (47) sampled residents experienced falls with major injuries. The facility's failure to have an effective system to ensure the Medical Director provided oversight of the residents medical care and failure to implement polices that was reflective of the current professional standards of practice has caused or is likely to cause serious harm or serious injury to the residents. [...]

Inspectors wroteBased on interview, record review, review of the facility's policies, documents, Executive Director's Job Description, and Plan of Correction (PoC) submitted for the 03/05/2020 Recertification Survey, it was determined the facility failed to have an effective process in place to address systemic failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility failed to develop and implement plans of action to correct identified quality of care deficiencies; and failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. [...]

Inspectors wroteBased on observation, interview and review of the facility's policy it was determined the facility failed to ensure each resident's right to privacy and confidentiality of his/her personal and medical records for the residents on the 100 Hall. On 05/31/2023, observations during the initial facility rounds, revealed on three (3) occasions, the screen of the computer was sitting on top of the 100 Hall medication cart. The computer had been left open with the resident's information visible to anyone passing by the cart.

Inspectors wroteBased on observation, interview, record review, and policy review, it was determined the facility failed to store all drugs and biologicals in locked compartments and under proper temperature control. In addition, the facility failed to ensure all medications and/or biological supplies stored on the 200 Hallway medication storage room had not expired. On 05/31/2023, 06/01/2023, and again on 06/09/2023, three (3) licensed nurses assigned to medication (med) carts on the 100 and 200 hallways failed to lock their med carts when away from the carts. On 06/07/2023, the thermometer in the medication refrigerator on the 300 Hallway, registered 64 degrees Fahrenheit.(F). However, according to the log posted on the refrigerator door, the refrigerator temperature should be below 41 degrees Fahrenheit. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to obtain informed consent for bed rail use for three (3) of twenty-four (24) sampled residents, Resident #40, #49, and #50 prior to utilizing the bed rails. Observations of Resident #40, Resident #49, and Resident #50 on 07/07/2021, 07/08/2021, and 07/09/2021 revealed bed rails were in use on the beds. Record review revealed no evidence that informed consent was provided prior to the use of bed rails.

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure a resident reported grievance was investigated per the facility's grievance policy/process for one (1) of twenty-three (23) sampled residents (Resident #75).

Inspectors wroteBased on interview, record review, and policy review, it was determined the facility failed to ensure Drug Regimen Review recommendations and physician orders, were acted upon for one (1) of twenty-three (23) sampled residents (Resident #98).