Stanley Post Acute

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Feb 23, 2022

  Based on observation interview and record review it was determined the facility failed to administer medications and treatments as ordered for 4 of 6 sampled residents (#s 10, 11, 17 and 27) reviewed for medications and catheter care. This placed residents at risk for adverse side effects of medication, worsening skin conditions and hospitalization . Findings include: 1. Resident 17 admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The revised 1/19/22 care plan indicated Resident 17 was diabetic and was to receive diabetic medications as ordered by the physician. The residents care plan also indicated she/he went to [CONDITION(S)] three days a week (Monday, Wednesday and Friday). […]

• Actual harm, isolatedF689Feb 20, 2026

  Based on interview and record review it was determined the facility failed to implement care plan interventions to prevent a fall for 1 of 3 sampled residents (#2) reviewed for falls. As a result, Resident 2 suffered bilateral femur fractures. Findings include:Resident 2 admitted to the facility in 2015 with diagnoses of diabetes and urinary incontinence.Resident 2's 1/9/26 MDS assessment indicated Resident 2 was dependent on staff for ADLs including bed mobility and toileting.Resident 2's Care Plan documented Resident 2 required two-person assistance and was dependent on staff for ADLs including toileting and bed mobility. […]

• No harm, potential for more than minimal, patternF880Sep 5, 2025

  Based on observation, interview and record review it was determined the facility failed to use appropriate disinfection practices for reusable medical equipment, failed to ensure the community use CBG glucometer was properly cleaned and sanitized between resident use, and failed to ensure hand hygiene was completed for 1 of 4 halls reviewed for infection control and meal service, and 1 of 1 sampled resident (#44) reviewed during medication pass. This placed all residents who required CBG checks at risk for exposure to infections including bloodborne illness and placed residents at risk for cross contamination. […]

• No harm, potential for more than minimal, patternF636May 20, 2024

  Based on interview and record review it was determined the facility failed to comprehensively assess 8 of 14 sampled residents (#s 25, 26, 32, 36, 52, 55, 57 and 114) reviewed for medications, pressure ulcers, ADLs, pain and nutrition. This placed residents at risk for unassessed needs. Findings include: 1. Resident 57 was admitted to the facility on ,d+[DATE] with diagnoses including chronic heart failure and diabetes. The 4/25/24 Admission MDS indicated Resident 57 received an antidepressant medication. The Psychotropic Drug Use CAA associated with the 4/25/24 MDS indicated psych meds per physician orders. […]

• No harm, potential for more than minimal, patternF730May 20, 2024

  Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 5 randomly selected CNAs (#s 15, 23, 24, and 25) reviewed for staff performance reviews. This placed residents at risk for lack of care by competent staff. Findings include: On 5/17/24 at 9:58 AM a review of facility personnel records with Staff 31 (Human Resource Director) indicated the following: - Staff 15 (CNA) was hired on 8/17/22; no annual performance review was completed. […]