Stanley Total Living Center

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to post cautionary and safety signage outside of resident rooms that indicated the use of oxygen for 3 of 3 residents reviewed for respiratory care (Residents #19, #88 and #41).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to verify and demonstrate competency for cleaning and disinfecting a shared glucometer according to the manufacturers' recommendations for using an Environmental Protection Agency (EPA) approved disinfectant cloth for 1 of 4 nursing staff reviewed for competent nurse staff. Nurse #1 was observed not disinfecting a shared glucometer after use on Resident #28 and before use on Resident #7. Failure to use an approved product and procedure to disinfect a glucometer in accordance with the manufacturer's instructions has the high likelihood to expose residents to bloodborne pathogens. Immediate jeopardy began on 10/23/24 when Nurse #1 failed to demonstrate competency in disinfecting a shared glucometer between residents. [...]

Inspectors wroteBased on observations, record review, staff and Nurse Practitioner interviews, the facility failed to disinfect a shared glucometer between Resident #28 and Resident #7 according to the facility's policy and the manufacturer's user guide. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer has the high likelihood to expose residents to bloodborne pathogens. None of the current residents were diagnosed with a bloodborne pathogen. This deficient practice affected 1 of 3 residents who required blood glucose levels checks (Resident #7). [...]

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to provide care in a safe manner, which resulted in the resident falling from her bed, striking her head on the corner of the bedside table, which resulted in a laceration to her scalp which required 5 sutures. This was for 1 of 3 residents reviewed for the prevention of accidents (Resident #139).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to develop a baseline care plan that addressed a resident's anticoagulant (blood thinner) medications for 1 of 3 resident reviewed for anticoagulant therapy (Resident #45). Resident #45 was admitted to the facility on [DATE] with diagnosis that included fracture of unspecified part of neck of right femur. Resident #45's care plan dated 10/1/24 did not include goals and interventions for the use of anticoagulant therapy. Record review revealed Resident #45 had an admission order for Enoxaparin Sodium Injection 40 milligram subcutaneously one time a day due to right hip fracture until 10/22/24. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #45 was cognitively intact. [...]

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to develop and implement a person-centered care plan for residents on anticoagulants for 2 of 3 residents reviewed for development and implementation of a comprehensive care plan (Resident #19 and Resident #34).

Inspectors wroteBased on record review, and interviews with staff and the Nurse Practitioner, the facility failed to limit the duration of a psychotropic medication (medication that may affect brain activities associated with mental processes and behavior) ordered on an as needed (PRN) basis to 14 days for 1 of 3 residents reviewed for unnecessary medications (Resident #19).

Inspectors wroteBased on record review, observations, staff, Psychiatric Nurse Practitioner, Consulting Pharmacist and Nurse Practitioner interviews the facility failed to notify the Physician and the Psychiatric Nurse Practitioner of Resident #17 ' s sexual behaviors towards two female residents (Resident #52 and Resident #11) on 4/4/2023 when Resident #17 touched the breast of Resident #52 and then grabbed his crotch and asked her if she wanted some of this and later the same day, Resident #17 touched the breast of Resident #11. On 4/10/2023, when Housekeeper #1 observed Resident #17 to put his hand on the leg of a female resident (Resident #11) and moved his hand up her leg towards her vaginal area. [...]

Inspectors wroteBased on record review, observation and interviews with staff, Consulting Pharmacist, Nurse Practitioner, Medical Director and the Psychiatric Nurse Practitioner (NP), the facility failed to protect the right of two severely cognitively impaired residents (Resident #52 and Resident #11) to be free of sexual abuse from Resident #17. Nurse #1 observed Resident #17 touch Resident #52 on the breast and then grab his crotch area and asked Resident #52, Do you want some of this? Nurse #1 also observed Resident #17 touch Resident #11 ' s breast. Housekeeper #1 observed Resident #17 put his hand up Resident #11 ' s dress. The Surveyor observed Resident #17 offering a female resident pudding and telling her to lick it and then roll by another female resident and make kissy faces at the resident. [...]

Inspectors wroteBased on record review, observations, staff, Psychiatric Nurse Practitioner, and Consulting Pharmacist interviews the facility failed to follow their abuse policy and procedure in the area of protection, identification, and reporting when they failed to implement measures to ensure residents were protected from Resident #17 who had sexual behaviors that included being observed on 4/4/2023, Resident #17 touch two female residents (Resident #52 and Resident #11) on their breasts and asked one of them, Do you want some of this? On 4/10/2023 Resident #17 was observed by Housekeeper #1 to put his hand on the leg of a female resident (Resident #11) and moved his hand up her leg towards her vaginal area. This failure placed all residents that resided on the memory impaired unit at high likelihood of suffering serious physical and psychosocial harm enacted by Resident #17. [...]