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Deficiency Records for Stanley Healthcare Center
A list of the most recent deficiencies for Stanley Healthcare Center. 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 Stanley Healthcare Center. 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 the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-04-23 | 2024-05-09 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2024-03-19 | 2024-04-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-19 | 2024-04-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-19 | 2024-04-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-19 | 2024-04-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-19 | 2024-04-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-19 | 2024-04-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-14 | 2024-04-07 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-03-14 | 2024-04-05 | N |
| Keep all essential equipment working safely. | Health | 2024-03-14 | 2024-04-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-14 | 2024-04-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-14 | 2024-04-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-03-14 | 2024-04-01 | 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 | 2024-03-14 | 2024-03-29 | 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 | 2024-03-14 | 2024-03-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-14 | 2024-03-27 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-03-14 | 2024-03-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-14 | 2024-03-25 | 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 | 2024-03-14 | 2024-03-25 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-03-14 | 2024-03-22 | N |
| Dispose of garbage and refuse properly. | Health | 2024-03-14 | 2024-03-22 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-03-14 | 2024-03-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-03-14 | 2024-03-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-14 | 2024-03-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-14 | 2024-03-19 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-03-14 | 2024-03-18 | 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 | 2024-03-14 | 2024-03-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-14 | 2024-03-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-05 | 2023-07-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-05 | 2023-07-05 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-05-05 | 2023-06-16 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-05-05 | 2023-06-16 | 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 | 2023-05-05 | 2023-06-16 | 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 | 2023-05-05 | 2023-06-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-05 | 2023-06-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-05 | 2023-06-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-05 | 2023-06-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-05 | 2023-06-16 | 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 | 2023-05-05 | 2023-06-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-05 | 2023-06-16 | 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 | 2023-05-05 | 2023-06-16 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-05-05 | 2023-06-16 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-05-05 | 2023-06-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-05 | 2023-06-16 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-05-05 | 2023-06-16 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-05-05 | 2023-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-05 | 2023-06-16 | N |
| Keep all essential equipment working safely. | Health | 2023-05-05 | 2023-06-16 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-05-05 | 2023-06-16 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-05-08 | 2023-05-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-08 | 2023-05-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-08 | 2023-05-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-08 | 2023-05-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-08 | 2023-05-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-08 | 2023-05-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-08 | 2023-05-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-08 | 2023-05-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-08 | 2023-05-23 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-03-11 | 2020-04-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-03-11 | 2020-04-02 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2020-03-11 | 2020-04-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-03-11 | 2020-04-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-11 | 2020-04-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-03-11 | 2020-04-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-24 | 2020-03-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-24 | 2020-03-09 | 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 | 2020-02-24 | 2020-03-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-24 | 2020-03-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-24 | 2020-03-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-24 | 2020-03-09 | N |
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