Stratford Commons Rehab & Health Care Center

Inspectors wroteThe facility identified a census of 53 residents, with three residents sampled for elopement risk. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent newly admitted Resident (R) 1, who had documented intermittent confusion and exit-seeking/wandering behaviors, from leaving the facility on 10/18/25 between 05:20 AM and 05:30 AM, without staff knowledge. R1 remained outside of the facility (whereabouts unknown) for approximately five and a half hours, wearing only a hospital gown and no shoes, in approximately 65 degrees Fahrenheit temperature. Law enforcement located R1 at 10:50 AM, approximately one mile from the facility, wearing a hospital gown and no shoes. The facility discovered the South egress door was not locked and did not alarm when pushed. This deficient practice placed R1 in immediate jeopardy.

Inspectors wroteThe facility had a census of 57 residents. The facility had six medication carts and two medication rooms. Based on observation, interview, and record review, the facility failed to remove outdated or expired medication from potential administration to residents.

Inspectors wroteThe facility identified a census of 57 residents. The facility identified 15 residents on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to follow sanitary infection control practices related to wearing personal protective equipment (PPE) related to residents on EBP.Findings Included: - On 09/30/25 at 07:36 AM, Certified Nurse Aide (CNA) M and CNA N used a total lift to transfer Resident (R) 23, who had wounds and a urinary catheter, from his bed to a wheelchair. The CNAs did not wear gowns for infection control during the transfer. [...]

Inspectors wroteThe facility reported a census of 57 residents. The sample included 15 residents reviewed for dignity. Based on observations, interviews, and record review, the facility failed to ensure a dignified care environment for Resident (R) 8 when staff spoke to her in a disrespectful manner when the resident asked for assistanceFindings Included:- R8's Electronic Medical Records (EMR) included diagnoses of depression, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cognitive communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), muscle weakness, and dysphagia (difficulty swallowing). R8's Quarterly Minimum Data Set (MDS) completed 07/31/25 indicated a Brief Interview for Mental Status (BIMS) score of 12, indicating mild cognitive impairment. [...]

Inspectors wroteThe facility reported a census of 57 residents. The sample included 15, with one reviewed for advance directives. Based on observations, interviews, and record review, the facility failed to follow Resident (R) 59's chosen advanced directives (legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves) related to her do not resuscitate (DNR) wishes for cardio pulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating). [...]

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents, with five reviewed for unnecessary drugs. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 6 was free from antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication use without a proper indication for use written by the physician.

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents, with six residents reviewed for pressure ulcers (PU- localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review, the facility failed to thoroughly assess Resident (R) 41's Stage three PU (full-thickness pressure injury extending through the skin into the tissue below) and Stage four PU (a deep pressure wound that reaches the muscles, ligaments, or even bone).

Inspectors wroteThe facility reported a census of 57 residents. The Sample included 15, with three reviewed for falls. Based on observations, record review, and interviews, the facility failed to implement Resident (R) 8's fall interventions related to fall prevention signs. Findings Included:- R8's Electronic Medical Records (EMR) included diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cognitive communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), muscle weakness, and dysphagia (difficulty swallowing). [...]

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 3 received care and services for dialysis (a procedure where impurities or wastes were removed from the blood) consistent with professional standards of practice, which include ongoing communication and collaboration with the dialysis facility.

Inspectors wroteThe facility identified a census of 54 residents. Based on observation, record review, and interviews, the facility failed to conduct a thorough, updated facility-wide assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 54 residents residing in the facility.

Inspectors wroteThe facility identified a census of 54 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to the implementation of procedures to monitor and prevent Legionella disease (Legionella is a bacterium that can cause pneumonia in vulnerable populations) or other opportunistic waterborne pathogens and failed to ensure sanitary storage of respiratory equipment. These deficient practices placed the residents at risk for complications related to infectious diseases.

Inspectors wroteThe facility identified a census of 54 residents. Based on record review and interview, the facility failed to ensure Licensed Nurse (LN) staff possessed the required skills and competencies to administer medication intravenously (IV- administered through a vein directly into the bloodstream). This placed all residents with IV medications at risk for medication errors and adverse outcomes. (Refer to F760)

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with 14 residents reviewed for care plans. Based on observation, record review, and interviews, the facility failed to revise the care plan with the relevant hospice information for Resident (R) 29. The facility also failed to revise R10's care plan with the unsuccessful attempts for nonpharmacological interventions that had been tried prior to the administration of as-needed psychotropic (alters mood or thoughts) medication. This deficient practice placed these residents at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility identified as census of 54 residents. The sample included 14 residents with two residents reviewed for discharge. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 24's discharge summary included medication reconciliation and instructions. This placed R24 at risk for not receiving timely and appropriate care.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with one sampled for activities of daily living (ADL). Based on observations, interviews, and record review, the facility failed to ensure Resident (R) 32 received supportive care and services to promote and maintain his quality of life when the facility did not implement tools and/or strategies to allow R32, who had aphasia (a condition with disordered or absent language function), to communicate his wants, needs, or feelings. This deficient practice placed the resident at risk for decreased quality of life, isolation, and impaired dignity.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with five residents reviewed for activities of daily living (ADLs). Based on observations, record review, and interviews, the facility failed to provide ADL care including trimming his fingernails/toenails for Resident (R) 5. The facility also failed to provide ADL care and assistance to R9. This deficient practice placed the residents at risk for poor hygiene, decreased self-esteem, and impaired health.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with 14 residents reviewed for quality of care. Based on observation, record review, and interview, the facility failed to apply Geri Sleeves (sleeves used to protect the skin on the arms and legs against damage caused by friction and shearing) to Resident (R) 23 per her care plan and the facility failed to follow physician ordered daily weights for R10 who required the use of a diuretic (a medication used for the formation and secretion of urine and reduce excess fluids). This deficient practice placed R23 at risk for skin injury and placed R10 at risk for excess fluid accumulation and physical complications.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with two sampled for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). based on observation, interviews, and record reviews the facility failed to ensure staff implemented the care plan interventions for Resident (R) 9 who had multiple pressure-related injuries and remained at risk for the development of pressure ulcers. This deficient practice placed R9 at risk for delayed healing, new pressure injuries, and related complications.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with three reviewed for range of motion. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 5 received services/interventions to prevent a reduction of range of motion (ROM) and contractures (abnormal permanent fixation of a joint or muscle). This deficient practice left R5 at risk for further decline and decreased ROM or mobility.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with three residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure staff followed the care plan for safe transfers for Resident (R) 29 and the facility also failed to ensure staff placed a fall mat next to R9's bed per his plan of care. These deficient practices placed these residents at risk for falls and possible injuries related to falls.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure there was a physician indication for oxygen administration for Resident (R)29 and failed to ensure the oxygen tubing was stored in a sanitary manner to decrease exposure and contamination. This placed R29 at increased risk for respiratory infection and complications.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with two residents reviewed for dialysis (a procedure where impurities or wastes were removed from the blood). Based on observation, record review, and interview, the facility failed to obtain Resident (R) 102's weight before hemodialysis (a machine filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) treatment. This placed R102 at risk for complications related to dialysis.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure nonpharmacological attempts of symptom management prior to administering as-needed psychotropic (alters mood or thought) medication for Resident (R) 10. The facility also failed to ensure a duration for an as-needed psychotropic medication for R101. These deficient practices placed these residents at risk for unnecessary psychotropic medication and related complications.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with two reviewed for discharge. Based on observation, record review, and interviews, the facility failed to prevent a significant medication error when Resident (R) 47 received an incorrect antibiotic (medication used to treat bacterial infections) intravenously (IV-administered via the vein directly into the bloodstream). This placed the resident at risk for adverse drug effects and ineffective antibiotic therapy.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider, and a failed to provide a description of the services, medication, and equipment provided to Resident (R) 29 by hospice. This deficient practice created a risk for missed or delayed services and impaired physical, and psychosocial care for R29.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to provide Resident (R)39 with the pneumococcal conjugate vaccine (PCV20- vaccination for bacterial lung infections) as consented. This placed R39 at increased risk for complications related to pneumonia ( bacterial infection in the lungs).

Inspectors wroteThe facility reported a census of 55 residents. Based on interview and record review, the facility failed to ensure principles of antibiotic stewardship were followed to ensure antibiotics were used in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance in an ongoing, proactive manner.

Inspectors wroteThe facility identified a census of 55 residents. The sample included 16 residents with five residents reviewed for activities of daily living (ADL's). Based on observation, record review, and interviews, the facility failed to provide consistent bathing opportunities for resident (R)27, R34, R16, R18, and R31. This deficient practice placed the residents at risk for decreased psychosocial wellbeing and increased skin complications. Findings Included: [...]

Inspectors wroteThe facility identified a census of 55 residents and one facility kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dining services related to food preparation, equipment cleaning and food storage during service. This deficient practice placed the residents at increased risk related to food borne illnesses and food safety concerns. Findings Included: - On 07/26/22 at 07:25 AM an initial kitchen walk-through revealed two staff members prepping food in the kitchen area were not wearing hairnets while working with food during the prepping of breakfast. At 07:26 AM Dietary Staff CC stated that the kitchen did not have any hairnets available at that time. An inspection of the dry food storage area revealed opened containers of pancake syrup, Worcestershire sauce, and peanut butter with no opened dates labeled. [...]

Inspectors wroteThe facility identified a census of 55 residents. Based on observations, record reviews, and interviews, the facility failed to maintain an effective quality assessment and assurance (QAA) program to identify quality issues and develop performance improvement plans. This deficient practice placed the resident's at risk for ineffective care. Findings Included: - The facility failed to ensure residents were provided Notice of Medicare Non-coverage (NOMNC) notices. (Refer to F582) The facility failed to ensure bathing and personal hygiene was provided for residents who required assistance from staff to complete the care. (Refer to F677) The facility failed to implement a physician order for daily weights to monitor for excess weight/fluid retention and failed to implement adequate blood glucose monitoring. [...]

Inspectors wroteThe facility identified a census of 55 residents. Based on observation, record review, and interview, the facility failed to ensure that proper hand hygiene was followed during peri-care for Resident (R) 21 and failed to ensure sanitary handling of a sling and disinfection of the Hoyer Lift (total body mechanical lift used to transfer residents) after use for R96. The facility failed to ensure sanitary storage of clean linens. These deficient practices put facility residents at risk for the spread of infections and/or communicable diseases. Findings Included: - On 07/26/22 at 08:00 AM an inspection of the Blue Hallway linen closet revealed clean towels, hospital gowns, sheets, rags, and Hoyer Lift slings stored on a metal rack. The clean linen shared a room with a sink, specimen refrigerator and trash can. No cover was observed over the clean linen rack. [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included 16 residents with five reviewed for vaccination status. Based on record reviews, and interviews, the facility failed to obtain influenza (highly contagious viral infection that attacks the lungs, nose, and throat and can be deadly in high-risk groups) vaccination and pneumococcal (pneumonia infection that inflames air sacs in one or both lungs which may fill with fluid) vaccination consents, declinations or administration information for Resident (R) 37, R10, and R35, and R18. This placed the residents at increased risk for influenza, pneumonia, and related complications.

Inspectors wroteThe facility identified a census of 55 residents with 16 residents included in the sample and three residents reviewed for beneficiary notification. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Notification of Medicare Non-Coverage (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service). The facility failed to complete the NOMNC for Resident (R)150. This placed the resident at risk for being uninformed of his rights for appeal and potential for financial liability related to the end of the Medicare Part A episode.

Inspectors wroteThe facility identified a census of 55 residents. The sample included 16 residents with two residents reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to provide diabetic (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) monitoring for Resident (R)95 who required an acute hospitalization for dangerously low blood glucose levels. The facility also failed to complete daily weights on R37 for her congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). This deficient practice placed R37 at risk for complications related to her CHF. Findings Included: [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included 16 residents with one reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure staff followed Resident (R) 18's plan of care which directed R18 required assistance of one staff with the use of a transfer belt for transfers. This placed R18, who had a history of falls, at increased risk for accidents and related injuries.

Inspectors wroteThe facility identified a census of 55 residents. The sample included 16 residents with four reviewed for bowel and bladder management and two reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) care. Based on observation, record review, and interviews, the facility failed to store Resident (R)11's urinary catheter in a sanitary manner to promoted dependent drainage without backflow. The facility additionally failed to provide R45 with a toileting program to prevent or reduce incontinence of bladder This deficient practice placed the residents at risk for complication related to urinary tract infections (UTI) and increased risk for incontinence. Findings Included: [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included 16 residents with one resident reviewed for hydration. Based on observation, record review, and interviews, the facility failed to provide consistent intravenous (IV - giving directly through the veins access) fluid therapy as ordered by the physician for Resident (R)11. This deficient practice placed the resident at risk for complication related to dehydration and related complications. Findings Included: [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included 16 residents. Based on observation, record review and interview the facility failed to ensure that Resident (R) 21's abdominal binder was applied as directed to avoid possible dislodging of his percutaneous endoscopic gastrostomy (PEG-tube placed through abdomen into stomach to allow liquid nutrition) feeding tube. The facility further failed to ensure sanitary care was provided for R31's gravity bag and tubing used to administer enteral (provided directly to the digestive system through an alternative opening such as a feeding tube) nutrition and failed to assess residual as ordered by the physician. This placed the residents at increased risks for complications related to enteral feedings. Findings Included: [...]

Inspectors wroteThe facility identified a census of 55 residents and identified one resident was positive for Covid (highly contagious, potentially life-threatening respiratory infection). The sample included 16 residents with two reviewed for respiratory services. Based on observation, record review and interviews, staff failed to ensure Resident (R)18's nebulizer tubing was stored in a sanitary manner to decrease exposure and contamination. This placed R18 at increased risk for respiratory infection and complications.

Inspectors wroteThe facility had a census of 55 residents. The sample included 16 residents with two reviewed for dialysis (blood purifying treatment given when kidney function is not optimum). Based on observation, interview, and record review the facility failed to obtain communication from the dialysis center regarding Resident (R) 16's and R146 health status with each procedure. The facility further failed to measure weights daily as ordered for R16 and R146, and obtain weekly labs for R16. This deficient practice placed R16 and R146 at risk for complication related to dialysis. Findings Included: [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included 16 residents with two residents reviewed for dementia (progressive mental disorder characterized by failing memory, confusion). Based on observations, record reviews, and interviews, the facility failed to provide dementia care and services to support Resident (R)18's highest practicable level of well-being. This deficient practice placed R18 at risk for decreased quality of life and impaired well-being due related to dementia.

Inspectors wroteThe facility identified a census of 55 residents. The sample included 16 residents with five residents reviewed for medication regimen review. Based on observation, record review, and interviews, the facility failed to ensure the Consulting Pharmacist (CP) identified and reported irregularities found with Resident (R)10's insulin (hormone used to treat/control blood glucose levels) administration and further failed to identify and report inappropriate diagnoses for antipsychotic (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing]and other mental emotional conditions) medication use for R18 and R37. This placed the affected residents at risk for unecessary medication treatment and related side effects. Findings Included: [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included 16 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to provide adequate monitor blood glucose (sugar) levels administer physician ordered insulin (medication used to control blood glucose levels) for Resident (R)10 and R37. This deficient practice placed the residents at risk for abnormal blood glucose levels and related complications. Findings Included: [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included 16 residents with five residents sampled for unnecessary medication review. Based on observation, record review and interview, the facility failed to ensure that Resident (R)37 and R18 had an appropriate diagnosis for their antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) medications: Abilify and Seroquel. This place R37 and R18 at risk for unnecessary antipsychotic medication administration and related side effects.

Inspectors wroteThe facility identified a census of 55 residents. The sample included 16 residents with two residents reviewed for hydration. Based on observations, record reviews, and interviews, the facility failed to respond to and provide Resident (R)18, who required thickened liquids, with her requested drinks during meal service. This deficient practice placed R18 at increased risk for dehydration and impaired comfort. Findings Included: [...]