Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stanford Court Skilled Nursing & Rehab Center during CMS and state inspections, most recent first.
The facility failed to provide dedicated vital signs equipment for two residents with C. diff infections, as required by their care plans and facility policy. Observations revealed the absence of such equipment in the residents' rooms, despite signs indicating the need for contact precautions. Interviews with staff confirmed the expectation for dedicated equipment to prevent infection spread.
The facility failed to follow proper infection control practices for two COVID-19 positive residents. Staff were observed wearing an N-95 mask over a surgical mask, compromising its effectiveness, and entering rooms without required face shields. Interviews confirmed these practices were against facility policy, which mandates proper PPE, including an N-95 mask, gown, gloves, and eye protection.
A facility failed to create a resident-centered care plan for a resident at high risk for falls. Despite a Fall Risk Evaluation indicating the high risk, the care plan did not reflect this. The Clinical Care Coordinator acknowledged the oversight, highlighting the importance of individualized care plans. The facility's policy requires care plans to be based on assessments and developed by an interdisciplinary team.
A facility failed to update a resident's care plan to reflect their high fall risk, despite assessments indicating increased risk. The resident, with hemiplegia and hemiparesis, was assessed as high risk for falls on multiple occasions, but the care plan still showed a moderate risk. The Clinical Care Coordinator acknowledged the discrepancy, noting the importance of accurate care plans for staff to prevent falls. The facility's policy lacked guidance on care plan revisions.
A resident, identified as high risk for falls due to conditions like morbid obesity and mobility issues, experienced a fall. The facility failed to conduct a thorough investigation to determine the cause of the fall and implement specific interventions. The Clinical Care Coordinator admitted the investigation was insufficient, not exploring the resident's actions leading to the fall, contrary to the facility's policy requiring cause identification within 24 hours.
The facility failed to provide palatable and flavorful meals, leading to resident dissatisfaction and potential nutritional issues. Residents reported repetitive menus, particularly with chicken, and meals often being cold and bland. The Dietary Supervisor and Registered Dietician acknowledged these issues, noting the potential for weight loss due to unappetizing food options.
The facility failed to maintain sanitary practices by using a low-temperature dishwasher that did not reach the required 120 F for proper sanitation. Despite knowing the temperature was insufficient, a Dietary Assistant continued to use the machine without notifying a supervisor. Another Dietary Assistant was aware of the issue but unsure of alternative cleaning methods. The Dietary Supervisor confirmed that staff should have reported the issue and used a three-compartment sink instead.
A resident's dignity was compromised when a staff member instructed them to urinate in a diaper instead of assisting with a bedpan or toilet. The resident, who was continent and typically used a bedpan, reported feeling terrible about the incident. The Director of Nurses confirmed that such instructions are demeaning and against the facility's rehabilitation goals. The facility's policy emphasizes care that promotes dignity and respect.
The facility failed to maintain a homelike environment for three residents due to damaged walls behind their beds. Observations showed scraped and peeling paint and drywall, and residents reported that maintenance had not assessed the damage. Staff were unaware of the issue, and the Environmental Service Director noted that mechanical beds caused the damage. The Director of Nursing acknowledged the importance of timely repairs to support a homelike setting.
A resident with schizoaffective disorder was not re-evaluated for PASARR after admission, despite being on antipsychotic medication. The case manager and DON acknowledged the oversight, noting the resident was not included in the PASARR review calendar, contrary to facility policy requiring such evaluations to ensure appropriate care and placement.
A resident was using a left-hand splint and had triamcinolone ointment without MD orders. The splint was applied by an RNA without documentation, and the ointment was left uncapped on the nightstand, posing risks of misuse. Facility policies require MD orders for such treatments, which were not followed, compromising the resident's care.
A resident with a history of hemiplegia and hemiparesis was found with long, dirty fingernails, indicating a failure in personal hygiene care. Despite being dependent on staff for hygiene, the resident's nail care was neglected, and hand splints were not consistently applied as per orders. Interviews with staff confirmed the lack of sufficient nail care, contrary to the facility's policy.
A resident with hemiplegia did not receive appropriate care as per professional standards. The resident's fingernails were neglected, remaining long and dirty, and the hand splint was not managed according to physician orders. Staff failed to remove the splint within the prescribed timeframe and did not provide necessary nail care, as confirmed by facility staff and policy reviews.
A resident with a peritoneal abscess and sepsis did not receive proper care for their drainage tube, as staff failed to consistently squeeze the accordion bulb to create necessary suction. Observations and interviews revealed a lack of understanding among staff about the correct procedure, leading to a deficiency in care.
The facility failed to securely store medications for two residents, leading to potential misuse and allergic reactions. A discontinued triamcinolone ointment was left uncapped on a resident's nightstand, and a prescribed Salonpas patch was stored at another resident's bedside without a self-administration safety screen. Facility policy requires medications to be stored in locked compartments, which was not followed in these cases.
Two residents in a LTC facility had food brought by family improperly stored, leading to potential health risks. One resident had fruits left at the bedside for over a week, while another had a sandwich, pastries, and a banana improperly stored. Facility policies requiring labeling and refrigeration were not followed, posing risks of spoilage and foodborne illness. Staff interviews confirmed the failure to adhere to these policies.
A facility failed to enforce neutropenic precautions for a resident with a low white blood cell count, allowing raw fruits in the resident's room despite policy prohibiting them. Staff interviews revealed inconsistencies in understanding and enforcing the precautions, with some staff allowing washed fruits and vegetables. The Director of Nursing acknowledged the oversight and emphasized the importance of following the protocol to protect the resident from infection.
A resident with severe cognitive impairment reported being physically abused by staff, but the incidents were not reported immediately as required by facility policy. A CNA witnessed the abuse but delayed reporting due to fear of gossip, leading to a failure in protecting the resident from further harm.
Failure to Provide Dedicated Equipment for Residents with C. diff
Penalty
Summary
The facility failed to ensure proper infection control practices by not designating dedicated vital signs (VS) equipment for two residents with Clostridium difficile (C. diff) infections. During observations, it was noted that the rooms of both residents had signs indicating the need for contact precautions and the use of dedicated or disposable equipment. However, the Certified Nurse Assistant (CNA) was unable to find any VS equipment in the rooms or on the carts outside the rooms. The care plans for both residents indicated the requirement for dedicated equipment due to their C. diff infections, but this was not adhered to. Interviews with facility staff, including a Licensed Nurse (LN), the Infection Preventionist (IP), and the Director of Nursing (DON), confirmed that dedicated VS equipment should have been available in the isolation rooms to prevent the spread of infection. The facility's policy on Clostridium Difficile, dated October 2018, also emphasized the importance of using dedicated medical equipment to prevent transmission. The lack of dedicated VS equipment for these residents posed a risk of spreading the infection throughout the facility.
Inadequate Infection Control Practices for COVID-19 Positive Residents
Penalty
Summary
The facility failed to adhere to current infection control practices for two residents who tested positive for COVID-19. Staff members were observed wearing an N-95 mask over a surgical mask, which was against the facility's policy and compromised the effectiveness of the N-95 mask. Certified Nurse Assistants (CNAs) and Licensed Nurses (LNs) were seen entering rooms of COVID-19 positive residents with improper personal protective equipment (PPE). Specifically, CNAs were observed wearing an N-95 mask over a surgical mask, and one LN entered a COVID-19 positive resident's room without a face shield, despite the precaution sign indicating the need for eye protection. Interviews with staff, including the Infection Prevention Nurse (IPN) and the Director of Nurses (DON), confirmed that the practice of double masking with an N-95 over a surgical mask was incorrect and compromised the seal of the N-95 mask. The IPN also stated that prescription glasses were not a substitute for a face shield, which was required for additional protection. The facility's policy, dated November 2024, clearly outlined the need for proper PPE, including an N-95 mask, gown, gloves, and eye protection, when entering the room of a resident with suspected or confirmed COVID-19 infection.
Failure to Develop Resident-Centered Care Plan for Fall Risk
Penalty
Summary
The facility failed to develop a resident-centered care plan for a resident identified as being at high risk for falls. This deficiency was identified during a review of the care plan for a resident who was readmitted to the facility with diagnoses including abnormalities of gait and mobility. Despite a Fall Risk Evaluation indicating the resident was at high risk for falls, the care plan did not reflect this risk. During an interview and joint record review, the Clinical Care Coordinator acknowledged that the care plan did not address the resident's individual concerns and needs, emphasizing the importance of developing a care plan tailored to each resident's specific requirements. The facility's policy on care planning, revised in March 2022, mandates that comprehensive, person-centered care plans be based on resident assessments and developed by an interdisciplinary team.
Failure to Revise Resident's Fall Risk Care Plan
Penalty
Summary
The facility failed to revise the care plan for a resident concerning their fall risk, which was identified during an interview and record review. The resident, who was readmitted with diagnoses of hemiplegia and hemiparesis, had a fall risk assessment indicating a moderate risk on 12/26/23, which later assessments on 2/20/24, 3/20/24, and 6/17/24 showed as high risk. However, the care plan dated 8/11/23 still reflected a moderate risk for falls. During an interview on 8/16/24, the Clinical Care Coordinator acknowledged that the care plan did not reflect the resident's current fall risk, which was necessary for staff to implement appropriate interventions to prevent falls. The facility's policy on care planning did not provide guidance on revising care plans.
Inadequate Fall Investigation for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident was free from future falls by not conducting a thorough investigation of the resident's fall. The resident, who was admitted with diagnoses including diverticulitis, morbid obesity, and gait and mobility abnormalities, was identified as high risk for falls. The resident experienced a fall and reported attempting to brace herself before falling. During an interview, the Clinical Care Coordinator acknowledged that the investigation into the fall was not thorough, as it did not explore what the resident was attempting to do when she tried to stand. The facility's policy requires identifying possible causes of falls within 24 hours, which was not adequately followed in this case.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, flavorful, and maintained its nutritional value, as observed during dining observations and interviews. Residents expressed dissatisfaction with the repetitive menu, particularly the frequent serving of chicken, and noted that meals were often cold and lacked flavor. Some residents reported relying on food brought by family members due to the unappetizing meals provided by the facility. The facility's menu on a specific date included pot roast and pureed options, which were found to be bland and salty during a test tray observation with the Dietary Supervisor. The facility's policy on taste testing, dated 2017, was not adhered to, as food that did not pass the taste test due to seasoning or other negative factors was still served. The Dietary Supervisor and Registered Dietician acknowledged the issues with the menu and the potential for weight loss among residents due to the lack of palatable food options. The Registered Dietician noted the need for a better nutritional menu equivalency for different meal textures, as residents were not receiving the planned menu items.
Improper Use of Low-Temperature Dishwasher
Penalty
Summary
The facility failed to maintain sanitary practices in the kitchen, specifically in the use of a low-temperature dishwasher. During an observation, it was noted that the dishwasher's temperature gauge read 111 F, below the required 120 F necessary for proper sanitation. Despite this, the Dietary Assistant (DA) 1 continued to use the machine without notifying a supervisor, contrary to the facility's policy. DA 1 acknowledged that the temperature was insufficient to kill germs and bacteria, yet proceeded to wash and store dishes as if they were sanitized. Further interviews revealed that another Dietary Assistant (DA 2) was also aware of the inadequate temperature but was unsure of alternative methods to clean the dishes if the dishwasher was not functioning properly. The Dietary Supervisor confirmed that staff should have reported the issue and used a three-compartment sink as an alternative. The failure to adhere to these procedures posed a risk of foodborne illness to the 90 residents served by the kitchen.
Resident Dignity Compromised by Inappropriate Care Instructions
Penalty
Summary
The facility failed to ensure that a resident's dignity was maintained when a staff member instructed the resident to urinate in a diaper instead of providing assistance to use a bedpan or toilet. Resident 178, who was admitted with a need for assistance with personal care, reported feeling terrible after being told to urinate in the diaper. The resident was continent and typically used a bedpan, as confirmed by CNA 11. This incident was observed and reported during interviews with the resident and staff. The Director of Nurses acknowledged that residents should not be instructed to urinate in diapers, as it is demeaning and contrary to the facility's rehabilitation goals. The facility's policy on dignity, dated June 16, 2016, emphasizes that residents should be cared for in a manner that promotes dignity, respect, and individuality. The care plan for Resident 178 indicated a need for assistance with toileting, highlighting the importance of providing appropriate support during activities of daily living.
Failure to Maintain Homelike Environment Due to Wall Damage
Penalty
Summary
The facility failed to provide a homelike environment for three residents due to damaged walls in their rooms. Observations revealed that the walls behind the beds of these residents were in disrepair, with paint and drywall scraped and peeling. Interviews with the residents indicated that maintenance had not assessed or repaired the damage, despite the residents' awareness of the issue. Staff members, including a CNA and an LN, were unaware of the disrepair and stated that the process for requesting maintenance involved filling out a repair slip at the nurse's station. The Environmental Service Director (ESD) was also unaware of the damage and explained that the mechanical beds were causing the scraping. The ESD mentioned that plastic protection sheets were being used to prevent further damage but acknowledged that complete repairs would require moving residents out of their rooms. The Director of Nursing (DON) confirmed that the damaged walls did not provide a homelike environment and emphasized the importance of timely communication with maintenance for repairs. The facility's policy on maintaining a homelike environment highlighted the need for a clean, sanitary, and orderly setting, which was not upheld in this instance.
Failure to Re-evaluate PASARR for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to re-evaluate a resident for the Pre-Admission Screening and Resident Review (PASARR), which is a federal requirement to ensure individuals with mental illness, developmental disability, or intellectual disability are appropriately placed in nursing homes. The resident in question was admitted with a diagnosis of schizoaffective disorder and was on antipsychotic medication. Despite these indicators, the resident was not included in the facility's PASARR review calendar for the month following their admission. The case manager acknowledged that a PASARR Level I review should have been conducted at the facility, given the resident's diagnosis and medication. The Director of Nurses also confirmed that the PASARR should have been re-evaluated to ensure the resident received proper care and to determine if a different placement was necessary. The facility's policy and procedure on PASARR indicated that such screenings are essential to determine the appropriateness of nursing facility care and the need for specialized services, but this was not adhered to in this case.
Failure to Obtain MD Orders for Splint and Medication Use
Penalty
Summary
The facility failed to provide services meeting professional standards of practice for Resident 47, who was using a left-hand splint without a Medical Doctor's (MD) order. Resident 47, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was observed using the splint without proper documentation or orders. The Restorative Nursing Assistant (RNA) applied the splint but did not chart its use due to the absence of an MD order, which is required for such devices. The Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that all splints need MD orders to ensure proper monitoring and prevent complications. Additionally, Resident 47 was found to have triamcinolone ointment on their nightstand without an MD order. The ointment, used to treat skin irritation, was left uncapped and accessible, posing a risk of misuse or allergic reactions. The licensed nurse (LN) and DSD confirmed that all treatments, including ointments, require MD orders and should be stored securely. The ointment was not prescribed, and there was no evaluation for self-administration, leading to its improper storage and potential for cross-contamination. The facility's policies require MD orders for both splint use and medication administration, which were not followed in these instances. The lack of proper orders and documentation for the splint and ointment use highlights a failure in adhering to professional standards, potentially compromising Resident 47's safety and care.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide necessary care to maintain good grooming and personal hygiene for a resident who required dependent assistance. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was observed with long, thick, yellowish-brown fingernails with dirt-like debris underneath and old chipped nail polish. Despite having no cognitive deficits, the resident was dependent on staff for personal hygiene. Observations and interviews revealed that the resident's hand splint was not consistently applied as per the physician's orders, and nail care was neglected. Interviews with the restorative nursing assistant and the Director of Staff Development confirmed that the resident's nail care was insufficient, as the nails were long and dirty. The Director of Nursing also acknowledged that the resident was not receiving appropriate nail care. The facility's policy on nail care, which includes daily cleaning and regular trimming to prevent infections, was not followed, leading to the deficiency in maintaining the resident's personal hygiene.
Deficiency in Care for Resident with Hemiplegia
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards for Resident 15, who required dependent assistance. Resident 15 was readmitted with a history of hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side. Despite having no cognitive deficits, Resident 15 was dependent on staff for personal hygiene. Observations revealed that Resident 15's fingernails were long, thick, yellowish brown, with debris underneath, and old chipped nail polish, indicating a lack of nail care. Additionally, Resident 15's left hand, which required a splint due to contracture, was not consistently managed according to physician orders. On multiple occasions, Resident 15 reported that the staff only applied the hand splint sporadically and could not recall the last time nail care was provided. Observations confirmed that the splint was not removed within the prescribed four to six hours, and hand hygiene was neglected. The restorative nursing assistant acknowledged the oversight, noting that the splint was applied at 10:15 A.M. on one day and was not removed until the following day, contrary to the physician's orders. The assistant also admitted that Resident 15's nails were dirty and should have been cleaned and clipped. Interviews with the Director of Staff Development and the Director of Nursing corroborated the findings. They confirmed that the splint should have been removed within the specified timeframe and that nail care should have been provided. The facility's policy required that dependent residents receive necessary services to maintain grooming and hygiene, which was not adhered to in this case. The Director of Nursing emphasized the importance of following physician orders to prevent risks such as skin breakdown and infection, which were not adequately addressed for Resident 15.
Inadequate Care of Resident's Drainage Tube
Penalty
Summary
The facility failed to appropriately care for a resident's drainage tube, which was necessary for managing a peritoneal abscess and sepsis. The resident, who was admitted with these conditions, reported that the staff did not properly maintain the drainage tube, specifically noting that the accordion bulb had not been squeezed for two days. Observations confirmed that the bulb was not squeezed, which is essential for creating suction to drain fluid effectively. The physician's orders and hospital records indicated that the bulb should be squeezed to prevent infection and promote healing. Interviews with nursing staff revealed inconsistencies in understanding and executing the care required for the drainage tube. The treatment nurse stated that the bulb must be squeezed to create suction, while another nurse incorrectly believed the drain worked by gravity and did not require squeezing. The Director of Nurses confirmed that the bulb should be squeezed to remove fluids, aligning with the facility's policy on maintaining negative pressure for drainage. This lack of consistent and correct practice among staff members led to the deficiency in care for the resident's drainage tube.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications securely for two residents, leading to potential risks of medication misuse and allergic reactions. For one resident, a discontinued order for triamcinolone ointment was found uncapped and unsecured on the nightstand table. Despite the resident having no cognitive deficits, the ointment was left unattended, and there were no current orders for its use in the resident's clinical chart. Interviews with the Licensed Nurse and Director of Staff Development confirmed that the ointment should have been discarded or stored securely in a treatment cart. Another resident had a prescribed Salonpas pain patch stored on the bedside table without a self-administration safety screen. The resident had mild cognitive deficits, and the presence of the medication at the bedside was inappropriate as it required safe application and proper storage to maintain its effectiveness. The Licensed Nurse and Director of Staff Development acknowledged that the Salonpas should have been stored in the medication cart due to the lack of a self-administration evaluation. The facility's policy on medication labeling and storage, revised in February 2023, mandates that all medications and biologicals be stored in locked compartments with access limited to authorized personnel. The Director of Nursing reiterated the importance of storing medications securely to prevent misuse and preserve their effectiveness, highlighting the potential for severe allergic reactions if not properly monitored and administered.
Improper Storage of Outside Food in LTC Facility
Penalty
Summary
The facility failed to store foods brought by family and visitors in a safe and sanitary manner according to their policies and procedures, affecting two residents. Resident 59 had a bag of unlabeled apples and oranges placed at the bedside for over a week. Despite the resident's cognitive ability to understand the situation, the fruits were not stored properly, posing a risk of spoilage and foodborne illness. The facility's policy required such items to be labeled and stored in a refrigerator, but this was not followed. Additionally, the presence of fresh fruits and flowers in the room was inappropriate due to the roommate's neutropenic precautions, which require a sterile environment to prevent infection. Resident 47 also had unlabeled and improperly stored food items at the bedside, including a sandwich, chocolate pastries, and a banana. These items were not stored in a refrigerator or labeled as required by the facility's policy. The resident expressed dissatisfaction with the facility's food, leading to the family bringing outside food. However, the lack of proper storage and labeling increased the risk of spoilage and foodborne illness. The facility's policy mandates that perishable foods be stored in resealable containers with tightly fitting lids and labeled with the resident's name and use-by date. Interviews with staff, including a licensed nurse, the Director of Staff Development, and the Director of Nursing, confirmed the failure to adhere to the facility's policies. The staff acknowledged that the food items should have been stored in the designated refrigerator and labeled appropriately. The failure to follow these procedures not only posed health risks to the residents but also highlighted a lack of communication and enforcement of the facility's food storage policies.
Failure to Enforce Neutropenic Precautions
Penalty
Summary
The facility failed to maintain appropriate neutropenic precautions for Resident 58, who was admitted with a diagnosis of malignant neoplasm of the endometrium and had a low white blood cell count, making her prone to infections. Despite signage indicating neutropenic precautions, raw fruits were found in the room shared by Resident 58 and her roommate, Resident 59. Resident 59's daughter had brought the fruits weeks prior, and they were only removed after being noticed by state surveyors. Interviews with staff revealed inconsistencies in understanding and enforcing the neutropenic precautions, with some staff allowing washed fruits and vegetables, contrary to the facility's policy. The facility's policy, dated April 2018, clearly prohibited raw and partially cooked fruits and vegetables, as well as plants and flowers, in rooms of residents on neutropenic precautions. However, there was a lack of adherence to these guidelines, as evidenced by the presence of raw fruits in the room. Staff interviews indicated a lack of consistent enforcement of PPE use and visitor protocols, with some visitors not following gowning procedures. The Director of Nursing acknowledged the oversight and emphasized the importance of following the neutropenic protocol to protect Resident 58 from potential infection.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of an abuse allegation involving a resident with severe cognitive impairment. The resident, who was admitted with metabolic encephalopathy, reported being physically abused by staff members. The Director of Nurses (DON) was informed of the abuse by a licensed nurse (LN) two days after the incidents occurred. The abuse was witnessed by a certified nurse assistant (CNA) who did not report the incidents immediately due to fear of gossip, contrary to the facility's policy requiring immediate reporting within two hours. The incidents involved a CNA witnessing another CNA physically assaulting the resident on two separate occasions. The first incident involved the resident being slapped and sustaining a cut on the hand, while the second involved the resident being pushed and choked. Despite witnessing these events, the CNA delayed reporting them to the charge nurse until the following day. The facility's policy mandates immediate reporting of abuse allegations to prevent further harm to residents, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Santee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgemoor Hospital | 1.2 mi | — | 19 | 1 |
| Bradley Court | 2.1 mi | — | 0 | 0 |
| Parkside Health And Wellness Center | 3 mi | — | 0 | 0 |
| Somerset Subacute And Care | 3.1 mi | — | 2 | 0 |
| Lakeside Special Care Center | 3.2 mi | — | 0 | 0 |
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