Stanley Healthcare Center

In the surveyor’s words

From the most serious findings on record at Stanley Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF692May 5, 2023

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 1) received the appropriate services needed to maintain acceptable parameters of nutritional status when: 1. The facility failed to implement the interventions to maintain Resident 1's nutritional status when Resident 1 experienced the following insidious weight loss (gradual, unintended, progressive weight loss over time): - 4 lbs, (3%) from 12/2/22 to 1/4/23, - 10 lbs (7%) from 10/3/22 to 1/4/23, and - 12 lbs (8%) from 8/5/22 to 1/4/22. 2. The facility failed to ensure the nutrition evaluations were performed by a qualified Registered Dietitian. 3. […]

• No harm, potential for more than minimal, patternF725Apr 9, 2026

  Based on observation, interview, medical record review, facility P&P review, facility document review, and the California Code of Regulations review, the facility failed to ensure a staff member was onsite during the evening and night shift, who could provide the respiratory services to the residents, in accordance with the residents' plan of care. * For the past year, on the evening and night shift, the facility failed to ensure a staff member was on site at the facility, who could provide respiratory services to the residents with oxygen titration orders. These failures had the potential to result in negative health outcomes for the residents. […]

• No harm, potential for more than minimal, patternF812Apr 9, 2026

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen for 27 of 27 residents who consumed food prepared in the kitchen. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * Unlabeled and undated white powder was observed stored inside a plastic measuring cup on the countertop shelf. […]

• No harm, potential for more than minimal, patternF880Apr 9, 2026

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program for the months of May 2025 through February 2026. The facility conducted surveillance of the resident's infections only when the residents were prescribed antimicrobial medications and/or if the residents were diagnosed with an infection. The facility failed to determine whether the residents who exhibited the signs and symptoms of infection and were not prescribed antimicrobial medications met the facility's criteria for infection (utilizing McGeer's Criteria). […]

• No harm, potential for more than minimal, patternF812Mar 6, 2025

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the microwave utilized to warm up the food was maintained in sanitary condition and free of food residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue. […]