Stratford Specialty Care

Inspectors wroteBased on personnel record review, staff interview and policy review the facility failed to provide appropriate screening prior to employment for 1 of 5 employees reviewed for background checks. The facility reported a census of 39 residents.

Inspectors wroteBased on clinical record review, facility investigative file review, staff interviews, and facility policy review the facility failed to document on the Controlled Drug Count Record and the electronic Medication Administration Record (MAR) when liquid Morphine (opioid medication) was administered for 1 of 1 resident reviewed for controlled substance use (Resident #1). The facility also failed to consistently and accurately reconcile controlled medications. The facility reported a census of 39 residents.

Inspectors wroteBased on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facility's past 2 surveys, and staff interview, the facility failed to correct their own deficiencies for 3 of 3 areas of concern. The facility reported a census of 39 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment and protect residents from inappropriate sexual behaviors for 2 of 2 residents reviewed (Residents #3 and #31). The facility reported a census of 39 residents.

Inspectors wroteBased on observations, interviews, clinical record reviews, and facility policy review the facility failed to report an allegation of sexual abuse for a resident with an unknown capacity to consent for 2 of 2 residents reviewed (Residents #3 and #31). The facility failed to report the allegation of sexual abuse after the residents progressed to fondling each other over clothing and then to touching without clothing. The facility reported a census of 39 residents.

Inspectors wroteBased on clinical record review, observations, interviews, and policy review the facility failed to separate residents with the unknown capacity to consent in sexual relations for 2 of 2 residents reviewed (Residents #3 and #31). See F600 for additional information regarding Resident #3 and #31. The facility reported a census of 39 residents.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure staff administered medications in accordance with physician orders for 1 of 2 residents reviewed for skin conditions (Resident #9). The facility reported a census of 39.

Inspectors wroteBased on observation, staff interviews, and policy review the facility failed to prepare and serve pureed food to meet the nutritional needs of 2 of 3 residents reviewed (Residents #17 and #28). The facility reported a census of 39 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff followed dietary orders for Resident #27. The facility reported a census of 39 residents.

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to have a complete and accurately documented medical record for 2 of 13 residents reviewed (Residents #33 and #4). The facility reported a census of 39 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 4 resident reviewed (Resident #33 and #18) during medication administration. The facility reported a census of 39 residents.

Inspectors wroteBased on resident interviews, staff interviews and policy review, the facility failed to provide care for 2 out of 8 residents reviewed (Resident #5 and #7) in a manner to promote dignity and respect. The facility reported a census of 37 residents.

Inspectors wroteBased on interviews, clinical record reviews, and policy review, the facility failed to notify the physician following an allegation of abuse for 1 of 1 resident reviewed for abuse (Resident #1). The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to protect a resident from the use of physical restraints for 1 of 1 residents reviewed (Resident #1). The facility reported a census of 37 residents.

Inspectors wroteBased on staff interviews, personnel record review, facility investigation review, and policy review the facility failed to notify DIAL (Department of Inspection, Appeals and Licensing) of an allegation of abuse for Resident #1 that occurred on 11/19/25 at 6:59 AM in a timely manner. In addition, the facility failed to notify the police of the allegation of abuse. The Maintenance Supervisor reported he told the ADON (Assistant Director of Nursing) of the allegations of abuse on the morning of 11/19/25 at 9:15 AM. The facility investigation for the alleged abuse was initiated on 11/20/25 after the Maintenance Supervisor reported it to the Administrator. The facility reported the incident to DIAL on 11/20/25 at 8:16 PM. The facility reported a census of 37 residents.

Inspectors wroteBased on staff interviews, personnel record review, facility investigation review, and policy review the facility failed to separate a staff member from dependent residents accused of alleged abuse that occurred on 11/19/25 at 6:59 AM for Resident #1. The Maintenance Supervisor told the Assistant Director of Nursing (ADON) of the allegations of abuse on 11/19/25 at 9:15 AM. The ADON did not inform the Administrator of the allegations, did not start an investigation and did not separate the staff member from the resident. On 11/20/25 around 3:48 PM, the Maintenance Supervisor reported the allegations of abuse to the Administrator via text. The staff member worked full shifts on 11/19 and 11/20. The facility reported a census of 37 residents.

Inspectors wroteBased on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facility's past surveys, and staff interview, the facility failed to correct their own deficiencies for 1 of concern. The facility reported a census of 36 residents.

Inspectors wroteBased on clinical record review, Payroll Based Journal (PBJ) data, staff, and resident interviews, the facility failed to provide enough staff to care for residents in a timely manner. The facility reported a census of 36 residents.

Inspectors wroteBased on clinical record review, staff interviews and review of Medicare guidelines, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNFABN) form for 2 of 2 residents (Resident #33 and #27) whose skilled stay ended and they continued to reside in the facility. The facility reported a census of 36 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews and policy review, the facility failed to complete and document appropriate assessments and interventions for the necessary care and services, to maintain the residents' highest practical physical well being for 1 of 1 residents reviewed (Resident #13). The facility failed to immediately assess Resident #13 after she was lowered to the floor and scraped her back on the wheelchair.

Inspectors wroteBased on observations, interviews, facility policy review, and record review, the facility failed to ensure the safety of 2 residents reviewed (Residents #13 and #14) for safety and nursing supervision. After Resident #13 took themselves to the bathroom, the staff failed to use the required staff to assisted them after they found them on the toilet. In addition, the staff member left Resident #13 in the bathroom alone. This allowed Resident #13 to get up from the toilet to attempt to self-transfer. The staff member intercepted Resident #13 and lowered her to the floor as her knees gave out. With Resident #14, when they fell the facility failed to put an intervention in place to prevent future falls. The facility reported a census of 36 residents.

Inspectors wroteBased on observations, interviews, policy review, and clinical record review, the facility failed to have orders for verifying the amount of water to flush the feeding tube when administering medications for 1 of 1 residents reviewed (Resident #35). The facility reported a census of 36 residents.

Inspectors wroteBased on observations, record review, staff interviews, resident interview and policy review, the facility failed to change nebulizer tubing for 1 of 1 resident reviewed (Resident #33) for respiratory services. The facility reported a census of 36 residents. Findings Include: The Minimum Data Set (MDS) assessment for Resident #33 dated 4/3/25 identified a Brief Interview for Mental Status (BIMS) score of 00, which indicated severely impaired cognition. The MDS included diagnoses of hypertension, cerebrovascular accident (CVA), aphasia (difficulty speaking) and dysphagia (difficulty swallowing). The MDS documented Resident #33 used a feeding tube while a resident in the last 7 days. On 5/18/25 at 9:24 AM, observed Resident #33's nebulizer machine sitting on the bed side table with the tubing connected to the machine and mask/chamber sitting behind the machine on the table. [...]

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #35) with a feeding-tube. In addition, the facility failed to complete adequate hand hygiene and gloving for 2 of 8 residents reviewed (Residents #29 and #21) during medication administration. The facility reported a census of 36 residents.

Inspectors wroteBased on clinical record review, policy/procedure review, resident and staff interview the facility failed to treat residents with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 10 resident reviewed. (Resident #9). The facility identified a census of 37 residents.

Inspectors wroteBased on record review, staff and resident interviews, the facility failed to ensure staff answered resident call lights and responded to resident needs in a timely manner, within fifteen minutes, for 3 out of 3 residents interviewed (Residents #2, #33 and #87). The facility reported a census of 34 residents.

Inspectors wroteBased on observations, staff interviews, and facility policy review the facility failed to prepare and serve food under sanitary conditions. The facility identified a census of 34 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to complete assessments for 1 of 1 resident reviewed (Resident #26) to determine if his abilities remained unchanged or declined. Resident #26 had impairment on both sides of his upper and lower extremities. He did not have a restorative nursing program. The facility reported a census of 34.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to change and label oxygen (O2) tubing for 1 of 2 residents reviewed (Resident #87). Review of Resident #87's July 2024 Medication Administration Record/Treatment Administration Record (MAR/TAR) reflected the facility failed to add weekly O2 tubing change on to Resident #87's record. The facility reported a census of 34 residents.

Inspectors wroteBased on record review, staff, and resident interviews, the facility failed to ensure staff answered resident call lights and responded to resident needs in a timely manner, within fifteen minutes, for 3 out of 3 residents interviewed (Residents #1, #3 and #7). The facility reported a census of 36 residents.

Inspectors wroteBased on observation, resident and staff interviews, the facility staff failed ensure residents could reach their call lights for 3 of 5 residents reviewed (Residents #3, #7 and #8).

Inspectors wroteBased on clinical record review, staff, and resident interviews, the facility failed to provide two baths a week as directed for 1 out of 4 residents reviewed (Resident #2).

Inspectors wroteBased on observation, staff interviews, facility policy, Center for Disease Control and Prevention (CDC) guidance the facility failed perform hand hygiene after staff touched their mask prior to delivering food; failed to put a barrier under medication supplies; and failed to remove (doffing) personal protective equipment (PPE) and complete hand hygiene after exiting a COVID positive room to prevent the spread of COVID-19 for residents. The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review, the facility failed to promptly identify and intervene for an acute change in a resident's condition after a fall for 1 of 4 residents reviewed (Resident #2). The facility failed to recognize the change in condition with Resident #2 as he rubbed his right knee and grimaced during cares for two days before an x-ray revealed a fracture in his hip.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review the facility failed to implement Care Plan interventions and adequate supervision to ensure the safety of residents at the facility following a resident to resident altercation on 8/6/23 for 2 of 3 residents reviewed (Residents #2 and #3). Resident #2 went into Resident #3's room as he slept. When Resident #3 woke up and asked Resident #2 to leave his room, Resident #2 hit Resident #3 with a shoehorn.

Inspectors wroteBased on clinical record review, facility policy review, staff, and physician interview, the facility failed to prevent medication errors for residents for 1 of 3 residents reviewed (Resident #1). The facility failed to administer an intramuscular medication as ordered, resulting in Resident #1 receiving more that his ordered medication dosage.