Stanly Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Oct 24, 2024

  Based on observation, record review, and interviews with hospital system's transportation staff (Driver #1), Passenger Services Manager and Nurse Practitioner (NP), the facility failed to leave Resident #45 in place for a clinical assessment of injury after a fall that occurred during transport. Resident #45 was being transported to dialysis in a hospital system owned transport van. Driver #1 made a sudden stop which caused Resident #45 to slide forward out his wheelchair onto the van floor when his seatbelt loosened. Driver #1 pulled the van into the median of the road and attempted to transfer Resident #45 back into his wheelchair. […]

• Immediate jeopardy, isolatedF689Oct 24, 2024

  Based on observations, record review, review of audio/video footage, and Nurse Practitioner (NP), Passenger Services Manager, resident and staff interviews, the facility failed to provide safe transportation for Resident #45 in the hospital system transportation van to the dialysis center. On 2/9/24 while en route Driver #1 stopped abruptly, and Resident #45 slid out of his wheelchair to the floor of the van. Driver #1 was unable to assist Resident #45 back into his wheelchair and proceeded to drive to the dialysis center with Resident #45 sitting on the floor of the van. In addition, on 8/12/24, Driver #1 failed to ensure the lift gate was in the elevated position before unloading Resident #62 from the back from the van. […]

• No harm, potential for more than minimal, widespreadF727May 25, 2023

  Based on record review and staff interviews the facility failed to have a Registered Nurse (RN) scheduled for 8 consecutive hours a day for 7 of 30 days (1/2/22, 1/3/22,1/8/22,1/9/22,1/15/22,1/16/22 and 1/8/23) reviewed for staffing. This failure had the potential to affect all residents in the facility. Findings included: A review of daily staffing assignment sheets and RN timecards for 1/1/22 through 1/15/22 and 1/1/23 to 1/15/23 revealed on 1/2/22, 1/3/22,1/8/22,1/9/22,1/15/22,1/16/22 there was no RN coverage in the facility. On 1/8/23 the staffing assignment sheet and RN timecard revealed an RN worked 4.5 hours out of the required 8 hours a day. A review of the posted daily staffing 1/1/22 through 1/15/22 and 1/1/23 to 1/15/23 revealed the census ranged from 42 to 46 residents. […]

• No harm, potential for more than minimal, patternF812Jan 8, 2026

  Based on observations and staff interviews, the facility failed to label and date open containers of food and discard expired food items in 1 of 1 walk-in cooler, and secure open food containers in the freezer, and prevent the freezer compressor from dripping condensation directly into open boxes stored under the compressor in 1 of 1 freezer.The findings included:a. The kitchen was toured on 1/5/26 with the Dietary Manager at 10:22 AM. During the observation, the walk-in cooler was observed to have an open container of liquid eggs. The container did not have a date when it was opened. The Dietary Manager reported that the eggs were used at breakfast on 1/5/26 and the cook should have labeled the open container. […]

• No harm, potential for more than minimal, patternF685Oct 24, 2024

  Based on observation, record review, and staff, family, resident and Nurse Practitioner (NP) interviews, the facility failed to obtain a referral, schedule or arrange an audiology appointment, or and screening for a resident with sensory neural hearing loss whose hearing aids did not fit properly for 1 of 1 resident (Resident #45) reviewed with hearing loss. The findings included: Resident #45 was admitted to the facility on [DATE] with a diagnosis that included cognitive decline and asymmetrical sensory-neural hearing loss. The care plan dated 1/22/24 indicated Resident #45 had a hearing deficit due to hearing loss as evidence by wearing bilateral hearing aids. The goal stated Resident #45 would understand verbal communication as evidence by appropriate response. […]