WESTMINSTER, CA - Federal inspectors found systematic medication errors, unsanitary kitchen conditions, and inadequate hospice coordination during a March inspection at Stanley Healthcare Center, resulting in multiple violations that put residents at risk.
Medication Administration Failures Create Safety Risks
The inspection revealed significant medication management failures affecting multiple residents. Two licensed vocational nurses (LVNs) were observed making critical errors during medication administration, resulting in an 11.11% medication error rate - more than double the federal threshold of 5%.
Both nurses incorrectly prepared polyethylene glycol, a laxative medication, by mixing it with only five ounces of water instead of the physician-ordered eight ounces. This seemingly minor error can significantly impact the medication's effectiveness. Polyethylene glycol works by drawing water into the intestines to stimulate bowel movements. When improperly diluted, the medication becomes more concentrated, potentially causing cramping, dehydration, or electrolyte imbalances.
Additionally, one nurse failed to administer a vitamin B12 supplement to a resident despite documenting it as given on the medication record. This practice, known as false documentation, represents a serious breach of medication safety protocols that could mask missed doses and lead to vitamin deficiencies over time.
The violations extended beyond preparation errors. An LVN administered laxative medications without assessing the resident's current bowel status, despite physician orders requiring evaluation for loose stools before administration. One nurse admitted that the resident "always wanted her laxatives," but proper assessment protocols exist specifically to prevent inappropriate medication use that could worsen existing conditions.
Kitchen Sanitation Violations Threaten Food Safety
The facility's kitchen was found to have multiple sanitation violations that could lead to foodborne illness among the 23 residents who receive meals prepared on-site. Inspectors discovered widespread contamination risks throughout the food preparation areas.
Kitchen equipment and utensils showed signs of neglect and improper maintenance. Multiple cooking utensils had melted handles, chipped surfaces, and fuzzy film residue. Ten different utensils were found with crusted food residue, dry spots, or deteriorated surfaces that could harbor dangerous bacteria. These conditions violate federal food safety standards that require smooth, cleanable surfaces on all food preparation equipment.
The microwave used to warm resident meals contained white crumbs on the interior glass plate, while the ventilation hood over the stove had accumulated black dirt residue. Four cutting boards showed heavy marring with deep grooves that create ideal breeding grounds for pathogenic microorganisms. Such contaminated surfaces can transfer harmful bacteria directly to food during preparation.
Food safety standards require these conditions because bacteria like Salmonella, E. coli, and Listeria can thrive in food residue and transfer to fresh food during preparation. For elderly nursing home residents with compromised immune systems, exposure to these pathogens can result in severe illness, hospitalization, or death.
Inadequate Pharmacy Oversight Compromises Medication Safety
The facility failed to properly follow up on pharmacy consultant recommendations, creating potential medication safety risks for residents. Consulting pharmacists conduct monthly reviews specifically to identify medication-related problems and suggest improvements, but their recommendations were not being addressed.
For one resident, the pharmacy consultant recommended limiting the duration of Preparation H treatment and switching from Benadryl to a less sedating antihistamine like Zyrtec or Claritin. First-generation antihistamines like Benadryl carry increased risks for elderly patients, including excessive sedation, confusion, and falls. The facility acknowledged these recommendations were not followed up until surveyors brought them to their attention.
Another resident had been receiving lorazepam, an anti-anxiety medication, on an as-needed basis without proper justification. Federal guidelines limit such psychotropic medications to 14 days unless specifically justified by the physician. The pharmacy consultant flagged this concern in February, but there was no documented evidence the facility addressed the recommendation with the prescribing physician.
Hospice Care Coordination Failures
Two residents receiving hospice services experienced coordination failures that could impact their end-of-life care quality. The facility lacked current hospice visit calendars, making it impossible for staff to know when hospice professionals would arrive or coordinate care effectively.
For one resident, documentation showed significant gaps in home health aide visits that were ordered twice weekly. The communication sheet showed only four documented visits over two months instead of the expected 16 visits. Additionally, the facility had outdated physician certifications and care plans from October 2024, despite the resident receiving ongoing hospice services through March 2025.
Another resident receiving hospice care for Alzheimer's disease had no care plan addressing hospice services in their facility records. This lack of coordination can result in conflicting treatments, missed symptom management opportunities, and poor communication between facility staff and hospice professionals.
Medical Standards and Industry Best Practices
Professional medication administration standards require nurses to follow the "five rights" of medication safety: right patient, right medication, right dose, right route, and right time. These protocols also mandate assessment before administering certain medications, particularly those that could be contraindicated based on current patient status.
Food safety in healthcare facilities must meet or exceed restaurant industry standards because residents have heightened vulnerability to foodborne illness. The USDA Food Code requires smooth, easily cleanable surfaces on all food preparation equipment and mandates regular cleaning schedules for ventilation systems to prevent contamination.
Hospice care coordination requires facilities to maintain current physician certifications, care plans, and visit schedules to ensure seamless integration between facility care and hospice services. This coordination becomes especially critical for managing pain, symptoms, and end-of-life comfort measures.
Additional Issues Identified
The inspection also found failures in the facility's quality assurance program, which is required to monitor and improve care delivery. The quality assessment and performance improvement (QAPI) committee had not developed adequate action plans for previously identified deficiencies, suggesting systemic problems with the facility's ability to implement lasting improvements.
These violations follow a pattern of regulatory concerns that indicate the need for comprehensive operational improvements across multiple departments. The facility's administrators acknowledged the findings during the inspection and committed to addressing the identified issues.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stanley Healthcare Center from 2025-03-06 including all violations, facility responses, and corrective action plans.
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