Stanford Crossing

In the surveyor’s words

From the most serious findings on record at Stanford Crossing, in the surveyor’s own words.

• Immediate jeopardy, patternF656Jun 10, 2023

  Based 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. […]

• Immediate jeopardy, patternF689Jun 10, 2023

  Based 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. […]

• Immediate jeopardy, patternF835Jun 10, 2023

  Based 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. […]

• Immediate jeopardy, patternF837Jun 10, 2023

  Based 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. […]

• Immediate jeopardy, patternF841Jun 10, 2023

  Based 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. […]