Stanford Crossing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled:11Number of residents cited: 7 Based on observations, interviews, record review, review of facility staffing documentation, and review of the facility's Payroll Based Journal (PBJ) report, the facility failed to ensure it had an effective system to provide sufficient numbers of qualified nursing staff to meet the needs of 6 of 51 sampled residents (Resident (R) 8, 18, 30, 68, 94 and 117). The findings include: Review of the facility's policy titled, Staffing, implemented 03/20/2025, revealed the purpose was to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Further review of the facility's staffing policy revealed the facility must ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility policy review the facility failed to provide housekeeping services to ensure a clean and sanitary environment for eight of 51 sampled residents (R) Residents ((R) 6, R7, R64, R37, R58, R70, R72, and R92). The findings include: Review of the facility's undated policy titled, Resident Rights, revealed the resident had a right to a safe, clean, comfortable and homelike environment. Review of the facility's housekeeping policy titled, Housekeeping Daily Duties, dated 12/2001, revealed a schedule of what housekeeping would do on each day of the week. The policy stated All corners and along all baseboards must be dust mopped to prevent buildup. When water pushes dust into corners, problems occur.1. On 12/04/2025 at 9:18 AM, observation of R6's room revealed a tile in the doorway that was cracked and potentially a fall hazard. Continued observation revealed that a handrail in the bathroom next to the toilet was loose and missing one of four screws. 2. On 12/04/2025 at 9:26 AM, observation of R7's room revealed five cracked tiles in the doorway…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure a care plan was developed and implemented for two of 51 sampled residents (Resident (R5 and R90). The findings include: 1.Review of the facility's policy titled, Comprehensive Care Plans, dated 04/06/2015 and revised 02/09/2024, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Closed record review of R5's face sheet revealed the facility admitted the resident on 04/22/2024. R5's readmission on [DATE] included diagnoses that included subsequent encounter for closed fracture with routine healing; personal history of Transient Ischemic Attack (TIA/stroke); and cerebral infarction without residual deficits, and difficulty in walking, not elsewhere classified. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (4) of 51 sampled residents (Resident (R)7, R28, R42 and R50).The findings include:Review of the facility's policy, titled Enhanced Barrier Precautions (EBP), dated 03/08/2024, revealed the EBP policy was implemented to reduce the transmission of multidrug-resistant organisms (MDROs) within the facility. The policy stated EBP would be utilized in conjunction with standard precautions to provide targeted gown and glove use during high-contact resident care activities. The policy stated high contact care activities included assisting with and providing hands on care.Review of the facility's policy titled Infection Control dated 03/10/2024, revealed that all nebulizer tubing should be in a sealed bag when not in use. The policy stated that it was okay…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility policy review, it was determined the facility failed to provide safe medication administration for one of 12 sampled residents. The findings include: Review of the undated facility policy titled Resident Rights revealed the resident had the right to be free from any medication errors and to receive the correct medication. Review of the undated facility policy Medication Administration revealed that the resident had the right to receive the correct medication at the correct time, and the correct dose. Review of the facilities investigative report revealed that Resident (R) 3 and R12 were housed in a room together and on 02/24/2025 they decided that they wanted to switch A bed and B bed positions. The facility switched the two bed positions and did not update the residents bed transfer in the computer system until the next day. On 02/24/2025 at medication pass Registered Nurse (RN)1 gave R3 medications that were supposed to be given to R12 due to failure to properly identify the correct resident. R3 received the following medications that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure its pharmaceutical services, to include procedures which assured the accurate acquiring and receiving of all controlled drugs, implemented its policy to prevent diversion for one (1) of thirty-five (35) sampled residents (Resident #49). Resident #49 was found to have missing controlled substance medications which could not be accounted for, and the facility was unable to locate them. The findings include: Review of the facility's policy titled, Controlled Substances, dated 06/21/2017, revealed the facility was to maintain a record and signed scheduled medication count at each change of shift (the Shift Count) by the on-coming nurse or authorized individual with off-going nurse or authorized individual, using a Controlled Drug Count Verification Form or using a facility approved form. Continued policy review revealed any discrepancies in the Shift Count must be immediately reported to the Director of Nursing (DON) for further action. Review of the facility's Final…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of the facility's policy it was determined the facility failed to ensure each resident's right to privacy and confidentiality of his/her personal and medical records for the residents on the 100 Hall. On 05/31/2023, observations during the initial facility rounds, revealed on three (3) occasions, the screen of the computer was sitting on top of the 100 Hall medication cart. The computer had been left open with the resident's information visible to anyone passing by the cart. The findings include: Review of the facility's policy titled, Resident Rights-Kentucky, effective date 01/09/2020, under the section,State Resident Rights, item number seven (7) revealed all residents shall have confidential treatment of their medical and personal records. Observations, on 05/31/2023 at 8:17 AM, 8:53 AM and 9:17 AM, revealed the medication cart, for the residents on the 100 Hall, was stationed across the hall from rooms [ROOM NUMBERS]. Further observations revealed the medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, it was determined the facility failed to store all drugs and biologicals in locked compartments and under proper temperature control. In addition, the facility failed to ensure all medications and/or biological supplies stored on the 200 Hallway medication storage room had not expired. On 05/31/2023, 06/01/2023, and again on 06/09/2023, three (3) licensed nurses assigned to medication (med) carts on the 100 and 200 hallways failed to lock their med carts when away from the carts. On 06/07/2023, the thermometer in the medication refrigerator on the 300 Hallway, registered 64 degrees Fahrenheit.(F). However, according to the log posted on the refrigerator door, the refrigerator temperature should be below 41 degrees Fahrenheit. Further review of the log posted on the refrigerator indicated temperatures had not been measured and documented twice daily in the month of June 2023. Observation, on 06/09/2023 of the 200 Hallway medication storage room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and policy review, the facility failed to obtain informed consent for bed rail use for three (3) of twenty-four (24) sampled residents, Resident #40, #49, and #50 prior to utilizing the bed rails. Observations of Resident #40, Resident #49, and Resident #50 on 07/07/2021, 07/08/2021, and 07/09/2021 revealed bed rails were in use on the beds. Record review revealed no evidence that informed consent was provided prior to the use of bed rails. The findings include: Review of the Bed Rail Use Policy dated March 13, 2018 revealed a licensed nurse would complete the bed rail assessment and consent upon admission, readmission, and quarterly. Further review of the policy revealed appropriate alternatives must be attempted and include documentation of how these alternatives failed to meet the resident need prior to installing bed rails. 1. Observation of Resident #49 on 07/07/2021 at 10:05 AM revealed half bed rails were on the resident's bed and were elevated. Observation of incontinence care on 07/08/2021 at 4:51 PM revealed two (2) staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined the facility failed to ensure a resident reported grievance was investigated per the facility's grievance policy/process for one (1) of twenty-three (23) sampled residents (Resident #75). The findings include: Review of facility policy titled Grievance/Concern Process dated 04/14/2020, revealed the purpose of policy was to establish a process for responding to a resident or resident representative's grievance. Per the policy, upon identification of a resident or resident representative concern, complete the grievance/concern form identifying the issue and forward the form to the Grievance Officer. Further review revealed the Grievance Officer then forwards the grievance/concern form to the appropriate department head for investigation. Once resolved, the grievance/concern form is updated with the resolution of the concern and returned to the Grievance Officer. Per the policy, the Grievance Officer or designee may complete a follow up call or meeting with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, it was determined the facility failed to ensure Drug Regimen Review recommendations and physician orders, were acted upon for one (1) of twenty-three (23) sampled residents (Resident #98). The findings include: The facility policy titled Medication Regimen Review: Facility Process dated 11/21/2017, revealed the process was in place to prevent or minimize adverse consequences related to medication therapy to the extent possible by providing oversight by a licensed pharmacist, attending physician, medical director, and the Director of Nursing. It further stated Medication Regimen Review is a thorough evaluation of medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risk associated with medications. The policy also stated Nursing will process any new orders as received from the physician. Review of Resident #98's facility record revealed the facility admitted the resident on 09/14/2015…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.