Inspection Reports for
Stanley Post Acute

Two initial comment citations were noted with no deficiencies corrected at the time of visit.

Nine citations including issues with resident rights, advance directives, mobility, drug labeling, dental services, infection control, and administrative rules. All deficiencies were corrected by 9/29/2025.

The facility was found deficient in multiple areas including failure to inform a resident about psychotropic medication risks, lack of resident advance directives in medical records, inconsistent provision of restorative range of motion services, improper labeling of medications, failure to assist a resident with obtaining dentures, and inadequate infection prevention practices including improper cleaning of reusable medical equipment and failure to perform hand hygiene.

The complaint investigation found that Resident 7 fell due to staff not following the care plan requiring two-person assistance during toileting. The fall was substantiated by interviews and record review.

The facility failed to ensure staff followed the care plan for toileting assistance for Resident 7, resulting in a fall when a staff member did not have the required second person assisting. The fall placed residents at risk for injuries.

Four citations including accident hazards and administrative rules. Deficiencies were corrected by 9/29/2025.

Two initial comment citations noted with no deficiencies corrected at the time of visit.

The complaint alleged that Resident 1 was discharged without referral to the resident's long-standing home health agency, and the facility referred the resident to a different agency that never made a home visit. The complaint was substantiated based on record review and interviews.

The facility failed to complete a discharge summary with necessary clinical information for one resident, risking unmet post-discharge needs. Additionally, the facility failed to administer prescribed medications as ordered for another resident, placing residents at risk for unmet medication needs.

Five citations including discharge summary, quality of care, and administrative rules. Some deficiencies corrected by 3/3/2025, others remained uncorrected.

Two initial comment citations noted with no deficiencies corrected at the time of visit.

The complaint investigation included allegations of mistreatment, medication self-administration issues, personal property concerns, incomplete assessments, care planning deficiencies, bowel care delays, inadequate foot care, unsafe smoking practices, respiratory care failures, pain management issues, staff performance review lapses, mental health care gaps, medication labeling errors, and record management problems. Mistreatment was ruled out but other deficiencies were substantiated.

The facility was found deficient in multiple areas including failure to ensure dignified treatment of residents, incomplete medication self-administration assessments, inadequate personal property management, incomplete resident assessments, lack of baseline care plans within 48 hours of admission, delayed bowel medication administration, insufficient foot care for diabetic residents, unsafe smoking practices, improper oxygen equipment maintenance, failure to provide timely pain medication, missing annual staff performance reviews, lack of follow-up mental health treatment, improper labeling of opened medication vials, and failure to safeguard resident identifiable information.

Seventeen citations covering resident rights, self-administration of meds, dignity, comprehensive assessments, baseline care plans, quality of care, foot care, accident hazards, respiratory care, pain management, nurse aide reviews, mental health treatment, drug labeling, resident records, and administrative rules. Many deficiencies corrected by 6/13/2024, others remained uncorrected.

The investigation was initiated due to complaints about resident dignity, medication administration, personal property loss, incomplete assessments, care planning deficiencies, foot care neglect, unsafe smoking practices, oxygen therapy issues, pain management failures, lack of staff performance reviews, unmet mental health needs, medication labeling errors, and improper record management.

The facility was found deficient in multiple areas including failure to ensure resident dignity, incomplete medication self-administration assessments, inadequate personal property management, incomplete resident assessments, lack of baseline care plans within 48 hours of admission, failure to provide timely bowel medication, inadequate foot care, unsafe smoking practices, improper oxygen therapy management, failure to provide ordered pain medication timely, lack of annual staff performance reviews, failure to provide mental health follow-up care, improper labeling of opened medication vials, and failure to safeguard resident identifiable information.

Two initial comment citations noted with no deficiencies corrected at the time of visit.

Two initial comment citations noted with no deficiencies corrected at the time of visit.

One citation for failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period. Deficiency was not corrected at time of visit.

The facility was found deficient in multiple areas including failure to provide residents the opportunity to formulate advance directives, failure to conduct significant change assessments, incomplete PASRR Level II screenings, inadequate care planning for anticoagulant medication monitoring, failure to provide necessary behavioral health services, medication administration errors, lack of qualified dietary staff, and improper food storage and handling practices.

The facility failed to properly prepare and store foods, including leaving uncovered food items in the kitchen and allowing curdled milk to remain in a resident's room, placing residents at risk of foodborne illness.