Stanford Court Skilled Nursing: Hand Splint Left On Overnight - CA
The resident at Stanford Court Skilled Nursing & Rehab Center also went without basic nail care, her fingernails growing long, thick and yellowish brown with dirt-like debris underneath and old chipped nail polish still visible on the tips.
Federal inspectors found the facility failed to follow physician orders for splint care and neglected personal hygiene for the stroke survivor, who had been readmitted with left-sided weakness following a brain attack that stopped blood flow to her brain.
The resident, identified as Resident 15 in inspection documents, had full cognitive abilities with no memory or reasoning deficits but required assistance with personal hygiene due to her stroke-related disabilities.
On July 31, 2024, inspectors observed the resident lying in bed without her prescribed hand splint. Her contracted left hand could only open enough to show half her palm, where her overgrown fingernails rested. Both hands displayed long, thick, yellowish brown nails with brown debris underneath and remnants of old brownish red polish.
"The staff puts on her hand splint only when they think of doing so," the resident told inspectors. She said she couldn't remember the last time staff applied the splint or provided nail care.
The next morning, inspectors returned to find the resident wearing her hand splint. Her fingernails remained unchanged from the previous day's observation. The resident confirmed nursing staff had not provided any nail care.
Records showed the resident's physician had ordered the palm guard splint to be worn five times per week for four to six hours as tolerated, with removal required for grooming and hygiene. The resident had showered at 1:13 PM on July 31, yet staff left the splint on overnight.
When a restorative nursing assistant removed the splint the following afternoon, the resident's left palm showed mild redness. "Hurting a bit," the resident said as staff moved her hand during splint removal.
The resident stated nursing staff had applied the splint after her morning shower the previous day and never removed it. The restorative nursing assistant confirmed the splint should have been removed within the four-to-six-hour timeframe per doctor's orders, not left on until the next day.
"Her fingernails are dirty, and I would not leave her like that," the restorative nursing assistant told inspectors. "I would clean and clipped them for sure."
The facility's Director of Staff Development reviewed the resident's records and confirmed she had no diabetes diagnosis, meaning nursing assistants should have been providing regular nail care during daily care activities.
"It did not look like Resident 15 was provided with sufficient nail care for both her hands because it should not be long and dirty," the director stated.
The Director of Nursing agreed the resident wasn't receiving appropriate nail care, noting the fingernails appeared "long, yellow, thick with noticeable old nail polish on the fingertips and dirty fingernails with dirt under the nail beds."
She also confirmed the hand splint should never have been left on overnight, stating physician orders should be followed to prevent risks for skin breakdown and infection from prolonged splint use.
The nursing director said her expectations included inspecting skin for breakdown, keeping nails trimmed to prevent infection from accidental injury, and maintaining clean fingernail beds.
The facility's own policies supported these standards. A March 2018 policy stated that residents unable to carry out daily living activities "receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene." An undated splint policy specified splints should be "applied on the a.m. shift and removed on the p.m. shift."
Inspectors also found staff confusion about proper drainage tube care for another resident. Resident 177, admitted with a life-threatening infection and peritoneal abscess, had a drainage tube with an accordion bulb that required regular squeezing to create suction and remove infected fluid.
The resident told inspectors staff hadn't properly squeezed the accordion bulb for two days. "The staff did not properly took care of it," the resident said.
Two licensed nurses gave conflicting information about the drainage system. One correctly stated the accordion bulb must be squeezed to create suction. Another incorrectly claimed the drain worked by gravity and the bulb only needed squeezing when emptying the bag.
Hospital records clearly indicated the drainage system required the "collection bulb at the end of the tube is squeezed and plugged to create suction" to prevent infection and promote healing. The facility's own policy confirmed "compression must be maintained on the bulb/accordion for suction to be preserved."
The Director of Nursing acknowledged the accordion bulb should be squeezed to create pressure for fluid removal but admitted it hadn't been squeezed when she checked on the resident.
A third licensed nurse explained that leaving the accordion bulb unsqueezed meant "the fluid remained inside the resident's site of infection which defeated the purpose of Resident 177's use of an antibiotic to clear the infection."
Inspectors also discovered medication storage violations, finding discontinued triamcinolone ointment left uncapped and unsecured on one resident's nightstand table instead of in locked storage as required.
The inspection revealed a pattern of staff failing to follow basic care protocols, from ignoring physician orders for splint removal to confusion about medical device operation and improper medication storage.
For the stroke patient with the neglected hand splint, the consequences were immediate and visible: pain, skin redness, and the indignity of overgrown, dirty fingernails that staff should have trimmed weeks earlier.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stanford Court Skilled Nursing & Rehab Center from 2024-08-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
STANFORD COURT SKILLED NURSING & REHAB CENTER in SANTEE, CA was cited for violations during a health inspection on August 2, 2024.
On July 31, 2024, inspectors observed the resident lying in bed without her prescribed hand splint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.