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Deficiency Records for Stanford Crossing
A list of the most recent deficiencies for Stanford Crossing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Stanford Crossing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-10 | 2023-07-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-10 | 2023-07-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-07 | 2023-07-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-07 | 2023-07-22 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-06-10 | 2023-07-20 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-06-10 | 2023-07-20 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-06-10 | 2023-07-20 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-06-10 | 2023-07-20 | Y |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2023-06-10 | 2023-07-20 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-06-10 | 2023-07-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-10 | 2023-07-20 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-06-10 | 2023-07-20 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-07 | 2023-07-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-07 | 2023-07-01 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-07-09 | 2021-07-27 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-07-09 | 2021-07-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-07-09 | 2021-07-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-07 | 2021-07-27 | N |
| Have exits that are accessible at all times. | Fire Safety | 2020-02-17 | 2020-09-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-17 | 2020-09-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-05 | 2020-04-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-03-05 | 2020-03-30 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-03-05 | 2020-03-30 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-03-05 | 2020-03-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-03-05 | 2020-03-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-03-05 | 2020-03-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-05 | 2020-03-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-03-05 | 2020-03-30 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-03-05 | 2020-03-30 | N |
| Post nurse staffing information every day. | Health | 2020-03-05 | 2020-03-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-03-05 | 2020-03-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-03-05 | 2020-03-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-03-05 | 2020-03-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-05 | 2020-03-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-05 | 2020-03-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-17 | 2020-03-30 | N |
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