Stratford Pines Nursing and Rehabilitation Center

Inspectors wroteThis citation is related to intake # 2676019Based on observation, interview, and record review, the facility failed to provide dignified care for 6 of 12 Confidential Resident Group Interview respondents and 3 residents (R36, R58, and R60) of 4 residents reviewed for dignity.

Inspectors wroteBased on interview and record review, the facility failed to inform residents of their right to maintain their current room or inform them of a room change prior to moving them for 4 Residents (R60, R101, R103 and R104) of 4 residents reviewed for notification of room change.

Inspectors wroteBased on interview and record review, the facility failed to formulate and implement a person-centered comprehensive psychosocial Care Plan in accordance with facility policy for one resident (R95) of three residents reviewed for comprehensive Care Plans.

Inspectors wroteBased on interview and record review, the facility failed to revise the comprehensive care plan with updated interventions to prevent the development or worsening of a pressure ulcer for 1 resident (R7) out of 19 residents reviewed for care planning.

Inspectors wroteBased on observation interview and record review, the facility failed to provide services to one Resident (R95) to maintain grooming standards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to gauge and ensure the activities of daily living (ADLs) did not diminish for one Resident (R95) of two residents reviewed for ADLs.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to promote healing and prevent worsening of a facility acquired pressure ulcer for 1 resident (R7) out of 1 resident reviewed for pressure ulcers. Findings Include:Resident #7 (R7)Review of an admission Record reflected R7 admitted to the facility with diagnoses that included lumbar spina bifida without hydrocephalus, pressure ulcer of left heel stage 2 (partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister), pressure ulcer of left buttock, unstageable (a severe wound with full thickness tissue loss, fully covered by slough or eschar, making its true depth hidden). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe transfer practices for 1 resident (R92) of 1 resident reviewed for accidents.

Inspectors wroteThis citation is related to intake # 2804821 Based on interview and record review, the facility failed to follow standards of care for one of two resident's (Resident #102) reviewed for peripherally inserted central catheter care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were labeled and dated correctly in 1 of 4 medication rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clear and concise medical records for two residents (R78 and R9) of 20 residents whose records were reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide collaborative hospice care for 2 Residents (R78 and R92).

Inspectors wroteBased on observation and interview, the facility failed to maintain comfortable room temperatures for 2 Residents (R58 and R60) of 2 residents reviewed for comfortable room temperatures.

Inspectors wroteThis citation pertains to intake number MI00151925 Falls Based on observation, interview and record review, the facility failed to provide adequate supervision, assistance and meaningful interventions to prevent falls for 2 residents (R1 & R6) of 4 residents reviewed for falls.

Inspectors wroteThis citation pertains to intake number MI00151925 Based on observations, interviews and record review, the facility failed to respond timely to resident concerns for 2 Residents (R3 and R4) of 3 residents reviewed for concerns.

Inspectors wroteThis citation pertains to intake MI00151925 Based on observations, interviews and record review the facility failed to ensure that 1 Resident (R4) of 4 residents reviewed for accident hazards met the required bed rail and mattress hazards entrapment assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policies and procedures for falls, implement meaningful care plan interventions, post fall neurological assessments, for two (R65 and R66), of three residents reviewed for accidents and supervision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physical facilities and equipment were maintained in proper condition potentially affecting all residents that receive food and beverages from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and/or the resident's responsible party, in advance of care, of the risks, benefits, and possible alternatives of treatment for the use of psychoactive medications for 1 of 1 resident (R71) reviewed for dementia care, resulting in the potential for the responsible party being uninformed of the resident's treatments and not able to choose to continue the treatments and/or choose an alternative preferred option.

Inspectors wroteBased on interview and record review, the facility failed to conduct a care conference timely for 1 of 18 sampled residents (R43), resulting in the potential for R43 and/or their responsible party not having an opportunity to participate in their person-centered plan of care and/or the planning process for their care.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's responsible party of the resident's preferred treatment options for 1 of 18 sampled residents (R71).

Inspectors wroteBased on observation and interview, the facility failed to formulate and implement a comprehensive, personalized Care Plan for one resident reviewed for Care Plans (R15) resulting in a comprehensive Care Plan without individualized or measurable interventions to assist the Resident to attain or maintain the highest practicable physical and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to address and provide assessments, catheter care, and wound care for one (R10) of three residents reviewed for skin conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative care, range of motion, and/or positioning devices for one (R10) of two residents reviewed for positioning and mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen therapy was received for one (R10) of three residents reviewed for respiratory care.

Inspectors wroteBased on interview and record review, the facility failed to 1) ensure clinical staff reviewed dialysis communication post dialysis and 2) ensure post dialysis monitoring for 1 resident (R11) of 1 resident reviewed for dialysis care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly labeled in 1 of 3 medication carts (Meadowbrook North Medication Cart) and 1 of 2 medication rooms (Meadowbrook South Medication Room) inspected. Findings Include: During an observation on 01/29/25 at 08:15 AM, the Meadowbrook North Medication Cart (as identified by staff) was inspected with Licensed Practical Nurse (LPN) J. R47's Breo-Elipta 100 micrograms (mcg)/25 mcg discus was observed in a box labeled with R47's name. However, the discus itself was not labeled with any identifying information (e.g., resident's name or resident's room number) that would indicate who the discus belonged to should it get separated from the box. LPN J stated the nurses usually do not label the discus with the resident's name because it already comes to the facility in a box that is labeled. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for three residents (R9, R65, and R71) of 18 residents reviewed for accuracy of medical records.

Inspectors wroteBased on interview and record review, the facility failed to implement appropriate infection control interventions, and root cause analysis for one (R71) of three residents reviewed for urinary tract infections.

Inspectors wroteThis citation pertains to intake # MI00148110 Based on interview and record review, the facility failed to provide increased supervision for 1 of 5 resident's (Resident #1) reviewed for falls, resulting in a fall with neck fractures and subsequent death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and prevent the development and worsening of pressure sores for one Resident (R39) of four reviewed for pressure sores, resulting in undocumented monitoring and worsening of pressure sores and increased pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident body weights were properly monitored and that documented changes were addressed timely for two of three Residents (R39 and R65) reviewed for close monitoring of weights, resulting in weight fluctuations greater than 5 lbs to not be assessed and/or followed up on per doctor's orders and standards of practice.

Inspectors wroteThis citation pertains to intake #: MI00135979 Based on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 2 residents (Resident #115 and #116) reviewed for the provision of nursing services, resulting in medication not administered following physician ordered parameters, the lack of assessment, monitoring, and documentation and the potential for the worsening of medical conditions.

Inspectors wroteThis citation pertains to intake #: MI00132466, MI00132485, and MI00139262 Based on observation, interview, and record review, the facility failed to prevent facility acquired pressure injuries and provide pressure ulcer preventative care for 3 residents (Resident #109, #111, and #112) reviewed for the risk of and/or the development of pressure injuries, resulting in the development of avoidable pressure injuries and the potential for ongoing skin breakdown and overall deterioration in health status.