Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stratford Specialty Care during CMS and state inspections, most recent first.
Failure to Complete Required Pre-Employment Background Screening: The facility failed to complete required pre-employment screening for an RN whose file lacked documentation of a SING prior to hire. The RN was actively working on the nursing schedule when the issue was identified, and the Administrator stated the facility could not locate the screening record. The facility policy required background and criminal checks for staff with direct resident access before employment.
A resident receiving Morphine for chronic pain and metastatic cancer had repeated gaps between the MAR and narcotic record, with staff signing out doses but often failing to document them on the MAR, and one dose appearing on the MAR without a matching narcotic entry. Controlled substance counts were also inconsistently reconciled, with missing signatures, subtraction errors, and a reported shortage in the liquid Morphine bottle. Staff interviews confirmed that the discrepancy had been noticed, but the count and documentation process was not consistently completed or reported to the DON.
QAPI failed to correct 3 repeat areas of concern identified on the current recertification survey that matched prior complaint and recertification citations: Infection Prevention and Control, Reporting of Alleged Violations, and Investigate/Prevent/Correct Alleged Violation. The facility's QAPI policy required data review, root cause analysis, system improvement, benchmarks, and communication of QAPI activities, and the Administrator acknowledged the repeat concerns and stated the QAPI committee needed more extensive audits to address them.
A facility failed to protect two cognitively impaired residents from inappropriate sexual behavior. One resident was severely cognitively impaired with dementia-related behaviors, and the other had moderately impaired cognition with diagnoses including dementia, anxiety, and other sexual disorders. Staff observed repeated kissing, holding hands, mutual touching, and fondling between the two residents, while the DON and Administrator treated the relationship as consensual based on body language and apparent enjoyment, without requesting capacity evaluations despite policy stating sexual contact with a resident lacking capacity to consent is abuse.
Failure to Report Alleged Sexual Abuse Between Two Cognitively Impaired Residents: Two residents with impaired cognition and sexually inappropriate behaviors progressed from kissing and holding hands to fondling and touching without clothing. The DON and Administrator treated the relationship as consensual based on apparent enjoyment and body language, did not obtain capacity evaluations, and did not report the incident as abuse even though facility policy defined sexual contact with a resident lacking the cognitive ability to consent as non-consensual and required immediate reporting.
A facility failed to separate two residents whose capacity to consent to sexual activity was unknown. One resident had severe cognitive impairment, dementia, and behavioral symptoms, while the other had moderate cognitive impairment, sexually inappropriate behaviors, and diagnoses including other sexual disorders and anxiety. Staff documented kissing, holding hands, and touching between the residents, and interviews showed the DON and Administrator treated the relationship as consensual based on enjoyment without obtaining capacity evaluations.
Medication administration did not match provider orders for a resident with severe cognitive impairment and a persistent groin/buttocks rash. Staff applied Econazole and Nystatin powder without clear orders, the eMAR lacked the Econazole order, and the DON/ADON confirmed the facility had not received or verified all dermatology paperwork. Interviews also showed confusion about which topical antifungals were ordered and which medications had been discontinued.
Pureed Diet Portions Not Measured Correctly Staff prepared pureed meat, vegetables, and rice for residents on a pureed diet, but the final blended food was not measured before service. A cook blended the foods with buns or tomato juice and placed them in containers without determining the final volume, then served the puree with a #8 scoop. The Dietary Manager stated the final blend should have been measured and matched to the correct scoop size, but it was not.
Improper Diet Texture Served to a Resident: A resident with a mechanical soft diet order was served corn relish instead of the ordered texture. Staff observed the cook send the item with meal trays to the locked unit, and the tray delivered to the resident contained the incorrect food before the Dietary Manager removed it and replaced it with the correct diet. The Dietary Manager stated the cook did not measure the pureed food after blending to verify the correct serving size.
Incomplete and inaccurate documentation was found for two residents. One resident’s narcotic record showed a RN signed another nurse’s name for a Pregabalin dose after the medication had been given, and the other resident’s TARs had multiple missing entries for ordered wound care, foot checks, and offloading/shoe use. The DON acknowledged the missing documentation and stated staff were not completing the TAR entries as expected.
Infection Control Lapses During Medication Administration: An RN discarded a used lancet in the garbage instead of a sharps container, despite the device instructions and DON expectations, while an LPN prepared and administered medications and eye drops using the same gloves after touching multiple surfaces on the med cart and then removed the gloves without hand hygiene. The facility’s hand hygiene policy required hand hygiene before donning gloves and after removing them, and stated that gloves do not replace handwashing.
Two residents with intact cognition were subjected to undignified and disrespectful treatment by an RN, including yelling, belittling language, physical restrictions to prevent standing, and threats to move a resident's bed into the hallway. Staff and resident interviews confirmed these actions, which did not align with facility policy requiring respectful and dignified care.
A resident with severe cognitive impairment and multiple medical conditions was involved in an alleged abuse incident where chairs were placed behind their wheelchair. The facility did not notify the physician immediately as required by policy, and documentation of physician notification was missing until days later due to staff miscommunication.
A resident with severe cognitive impairment and multiple medical conditions was found with two dining room chairs placed behind their wheelchair, restricting movement and preventing them from backing up or standing. Staff interviews confirmed the chairs were used to limit the resident's mobility due to supervision challenges, despite facility policy prohibiting such restraint use except for medical necessity. The use of these chairs was not medically indicated and was implemented for staff convenience, violating the facility's restraint policy.
A resident was found restrained in a wheelchair with chairs placed behind it, and although the situation was addressed by staff, the allegation of abuse was not reported to state authorities or law enforcement in a timely manner as required by facility policy. Delays in communication among staff and failure to recognize the incident as abuse led to late notification and a deficiency finding.
A staff member accused of abuse was not immediately separated from a resident after an incident involving the improper placement of chairs behind a wheelchair. The concern was reported to the ADON, who failed to notify the Administrator or initiate an investigation, allowing the staff member to continue working full shifts with resident contact for nearly two days, contrary to facility policy.
The facility did not resolve ongoing deficiencies related to sufficient nursing staff, as concerns about call light response times continued to be reported by residents during surveyor interviews. Despite the QAPI program and call light audits, the Administrator acknowledged that staff did not recognize or report these issues, and the deficiency persisted based on resident feedback.
The facility did not maintain adequate nursing staff to meet resident needs in a timely manner, as evidenced by reports of long call light response times, low weekend staffing, and staff exhaustion. A resident reported waiting up to 45 minutes for assistance, and staff described frequent understaffing, especially during evenings and weekends, making it difficult to complete essential care tasks and respond promptly to resident needs.
Two residents with severe cognitive impairment were not provided with the required Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNFABN) form when their Medicare Part A skilled stay ended and they remained in the facility under private pay. Clinical records lacked documentation of the notice, and staff confirmed the forms could not be located, despite facility policy requiring advance written notification of potential liability for non-covered services.
A resident with a feeding tube did not have physician orders specifying the amount of water to use for flushing the tube during medication administration. Nursing staff relied on facility protocol and outdated policies, which were not readily accessible, and there was no documentation of staff education or physician guidance on the matter. This resulted in inconsistent practices and a deficiency related to proper care for residents with feeding tubes.
A resident with severe cognitive impairment and multiple medical conditions was found with a nebulizer mask and tubing at the bedside that had not been changed or cleaned for several months, despite facility policy requiring weekly replacement and nightly cleaning. The equipment was visibly dirty and had not been removed after nebulizer treatments were discontinued.
Staff failed to follow infection prevention and control protocols during care of a resident with a feeding tube and during medication administration for two residents. An LPN did not wear a gown or change gloves as required by enhanced barrier precautions during a g-tube dressing change, and a CMA did not perform proper hand hygiene or gloving between residents and care tasks. These actions were not in accordance with facility policies and CDC guidelines.
A resident who required maximal assistance with transfers was lowered to the floor by a CNA after attempting to self-transfer, resulting in a back abrasion. Despite visible injury and staff attempts to notify the nurse, there was a significant delay before an RN assessed the resident, and the required head-to-toe assessment and documentation of the injury were not completed until the following day.
Two residents experienced falls due to staff failing to provide required supervision and assistance during transfers, and the facility did not implement new interventions after a fall as required by policy. One resident was left unattended in the bathroom and attempted to self-transfer, resulting in injury, while another resident's care plan was not updated after a fall. Delays in nursing assessment and lack of adherence to care plans contributed to these deficiencies.
A resident with intact cognition reported feeling uncomfortable with a CNA's joking behavior, which included questioning the resident's ability to remove their own socks. The resident expressed a desire for the joking to stop and to be treated with dignity and respect, highlighting a failure by the facility to uphold the resident's rights to a dignified existence.
The facility failed to ensure timely responses to resident call lights, with three residents reporting waits exceeding fifteen minutes. Despite having intact cognition and requiring significant assistance, these residents experienced delays, which they verified using clocks or watches. The DON confirmed the expectation for responses within fifteen minutes, as per facility policy.
The facility failed to maintain sanitary conditions during meal service. A cook did not perform hand hygiene before applying gloves and touched various items without changing gloves. The cook handled food with soiled gloves and continued serving the meal after washing hands and applying new gloves. The facility's policy requires handwashing before serving food and changing gloves between tasks.
A resident with impairments on both sides of his extremities did not receive a restorative nursing program despite therapy recommendations. The facility lacked documentation and an active restorative program, as revealed by interviews with the DON and other staff.
A facility failed to change and label oxygen tubing for a resident, as required for infection control. The resident's MAR/TAR lacked documentation for weekly tubing changes, and the resident reported that the tubing had not been changed since admission. The DON acknowledged the oversight, noting that the facility's practice was to change tubing every Sunday, but this was not documented.
The facility failed to respond to resident call lights within fifteen minutes, affecting three residents with intact cognition who required assistance for daily activities. Interviews with staff revealed inconsistent staffing levels, impacting response times. The ADON confirmed the expectation for timely responses, and the facility's policy outlined procedures to ensure call lights are functional and accessible.
Failure to Complete Required Pre-Employment Background Screening
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after the facility failed to complete appropriate pre-employment screening for 1 of 5 employees reviewed. The personnel file for Staff D, a Registered Nurse with a start date of 6/24/25, did not contain documentation that a Single Contact License and Background Check (SING) had been completed prior to hire. Current nursing schedules showed Staff D was actively working at the facility during the survey. On 7/8/26 at 4:30 PM, the Administrator stated the facility could not locate the SING for Staff D and said Staff D was sent home as a precautionary measure. The facility policy required background screening, reference checks, and criminal conviction investigations for applicants with direct access to residents, with checks initiated within two days of an offer and completed before employment.
Inconsistent Morphine Documentation and Controlled Substance Counts
Penalty
Summary
The facility failed to document administration of liquid Morphine on the electronic MAR and the Individual Narcotic Record for one resident receiving opioid medication for chronic pain and metastatic cancer. The resident’s care plan directed staff to administer opioid medication as ordered and monitor for side effects, and the May 2026 MAR ordered Morphine Sulfate Concentrate Oral Solution 20 mg/ml, 0.25 ml every 2 hours as needed for pain. Review of the narcotic records from March 28, 2026 through June 30, 2026 showed multiple instances where staff signed out Morphine on the Individual Narcotic Record but did not document the administration on the MAR, including 15 missed MAR entries, and one instance where Morphine was documented on the MAR but not on the narcotic record. The records also showed inconsistent controlled substance reconciliation and subtraction errors. On several dates, staff documented remaining quantities that did not match the amount that should have remained after administration, including a 0.5 ml discrepancy on one date, a subtraction error on another, and a 7.25 ml discrepancy on the date the facility later reported a shortage of 6.75 ml in the resident’s liquid Morphine count. The facility’s Controlled Drugs Count Record required staff signatures to verify the count, but multiple shifts and dates lacked signatures, showing that controlled medications were not consistently reconciled. Staff interviews reflected that the discrepancy had been noticed by nursing staff, but the exact shortage was not consistently recalled and the issue was not always reported to the DON. One RN stated the count difference had existed since her employment began and admitted failing to report it, while another RN described occasional missed signatures and acknowledged the expectation to sign the narcotic log and MAR immediately after administration. A CMA reported the Morphine bottle felt damp, had wet residue, and appeared nearly empty. The facility policy required staff to document the date, time, dose, signature, and remaining quantity on the narcotic sheet and to match the MAR entry to the Controlled Substance Record Book.
QAPI Program Failed to Correct Repeat Deficiencies
Penalty
Summary
The facility failed to correct its own deficiencies for 3 of 3 areas of concern identified during the current recertification survey. The concerns matched citations from the previous complaint survey and the previous recertification survey and involved Infection Prevention and Control, Reporting of Alleged Violations, and Investigate/Prevent/Correct Alleged Violation. The facility had a census of 39 residents at the time of the survey. The facility's QAPI Program policy, revised March 2020, directed the QAPI committee to collect and analyze performance indicator data, identify and monitor facility systems and processes, use root cause analysis, help departments implement systems to correct issues in quality of care, establish benchmarks and goals, coordinate performance improvement projects, and communicate QAPI activities to the Administrator and governing body. On 7/9/26 at 2:30 PM, the Administrator stated the QAPI committee reviews prior surveys and prior deficiencies to determine root cause and develop a plan to address and correct repeat deficiencies, and acknowledged the repeat concerns identified during this survey and prior surveys. The Administrator stated the QAPI committee must complete more extensive audits to address them.
Failure to Protect Cognitively Impaired Residents from Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to ensure a safe environment and protect residents from inappropriate sexual behaviors involving two residents with cognitive impairment. Resident #3 had a BIMS score of 3, was severely cognitively impaired, and had diagnoses including metabolic encephalopathy, Alzheimer’s disease with late onset, and a psychotic disorder. The resident’s assessments and care plan documented behavioral symptoms, impaired memory and decision-making, and a history of resident-to-resident altercations and sexually inappropriate behavior. The care plan also noted that the resident could act sexually inappropriate due to dementia. Resident #31 had moderately impaired cognition with diagnoses including other sexual disorders, adjustment disorder with depressed mood, anxiety, and dementia-related mood disturbance. The care plan identified sexually inappropriate actions related to dementia and noted medication used to decrease sexual inhibition. Facility documentation and staff reports described repeated sexual contact between the two residents, including kissing, holding hands, mutual touching, and an episode in which staff observed Resident #31 and another resident kissing in the dining area. Staff also reported seeing Resident #3 fondling Resident #31 through clothing and touching Resident #31’s inner thigh, and the DON acknowledged awareness of these behaviors. The facility treated the relationship as consensual based on observed enjoyment and body language, despite both residents’ cognitive impairment and the facility policy stating that sexual contact with a resident who lacks the cognitive ability to consent is non-consensual and constitutes abuse. The DON and Administrator stated they relied on the appearance of consent and did not request capacity evaluations, while staff and leadership allowed the relationship to continue in common areas with limited restrictions. The report also states that the facility did not report the behavior as abuse unless there was true sexual contact or resistance, and that management allowed the relationship to naturally evolve without intervention.
Failure to Report Alleged Sexual Abuse Between Two Cognitively Impaired Residents
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents whose capacity to consent was not established. Resident #3 had severe cognitive impairment on multiple MDS assessments, with diagnoses including metabolic encephalopathy, Alzheimer’s disease, and a psychotic disorder, and care plans noted impaired cognition, sexually inappropriate behavior, and involvement in a resident-to-resident altercation. Resident #31 had moderately impaired cognition, diagnoses including other sexual disorders, adjustment disorder with depressed mood, and anxiety, and care plans identified sexually inappropriate behavior related to dementia and use of medication to decrease sexual inhibition. Staff observed the relationship between the two residents progress from kissing and holding hands to fondling through clothing and then to touching without clothing. A CMA stated that Resident #3 and Resident #31 kissed and expressed mutual love, and that she once found Resident #3 fondling Resident #31 through clothing. The DON acknowledged awareness of the residents kissing, holding hands, a hand on the thigh, and an incident in which Resident #31 pulled his pants down while Resident #3 touched Resident #31’s penis in the dining room before staff intervened. The DON and Administrator did not report the behavior as abuse because they considered it consensual based on the residents’ apparent enjoyment and body language. They stated they did not request capacity evaluations and relied on discussions with the primary care provider and Resident #3’s representative, neither of whom declared Resident #3 lacked capacity to consent. The facility policy defined sexual abuse as non-consensual sexual conduct and stated that sexual contact with a resident who lacked the cognitive ability to consent is considered non-consensual and constitutes abuse, and that reports of resident abuse are to be immediately reported to the state licensing/certification agency within 2 hours of an allegation.
Failure to Separate Residents With Unknown Capacity for Sexual Consent
Penalty
Summary
The facility failed to separate two residents whose capacity to consent in sexual relations was unknown. One resident had a BIMS score of 3 on multiple assessments, indicating severe cognitive impairment, with diagnoses including metabolic encephalopathy, Alzheimer's disease with late onset, and a psychotic disorder. That resident also had documented physical and verbal behavioral symptoms, rarely or never was understood by staff, could not recall basic orientation information, and was assessed as having severely impaired cognitive skills for daily decision-making. The care plan identified impaired cognition, behavioral symptoms, resident-to-resident altercations, and sexually inappropriate behavior related to dementia. The second resident had a BIMS score of 11, indicating moderately impaired cognition, and exhibited physical and verbal behavioral symptoms including public sexual acts and disrobing in public. Diagnoses included other sexual disorders, adjustment disorder with depressed mood, and anxiety, and the resident received an antidepressant during the lookback period. The care plan identified sexually inappropriate behavior related to dementia and included an intervention noting the resident took medication to help decrease sexual inhibition, which carried a black box warning. Staff documented repeated sexual contact between the two residents, including kissing, holding hands, and touching. A late-entry incident note described staff finding the residents kissing in the dining area and separating them, with notifications made to the DON, Administrator, sheriff, and the resident representative. Staff interviews confirmed the residents kissed, held hands, and engaged in mutual touching, and one staff member reported finding one resident fondling the other through clothing. The DON and Administrator stated they considered the relationship consensual based on enjoyment and did not request capacity evaluations, while the Administrator stated the facility did not report the behavior as abuse unless there was true sexual contact or resistance. The facility policy required reports of abuse, neglect, exploitation, misappropriation, or injury of unknown source to be reported and investigated.
Medication Administration Did Not Match Skin Treatment Orders
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders for a resident with severe cognitive impairment, hypertension, diabetes mellitus, non-Alzheimer's dementia, and moisture associated skin damage. The resident had a rash to the scrotum and buttocks, and the care plan identified a potential or actual skin impairment. Orders over time included topical antifungals, Triad paste, oral fluconazole, and later dermatology-directed treatment for rash involving the groin, thighs, buttocks, face, eyelid, and ears. The record showed multiple changes to the resident’s skin treatment regimen, including discontinuation of Nystatin cream, initiation of miconazole cream, later restart of Nystatin cream and prednisone, and then dermatology orders for fluconazole, econazole nitrate cream, and nystatin-triamcinolone ointment. The July MAR listed fluconazole, nystatin-triamcinolone ointment, and Triad paste orders, including one Triad order for incontinence episodes and another for every 3 hours as needed. During observation on 7/7/26, Staff L and the DON completed incontinence care and ointment application, and Staff L applied Econazole Nitrate 1% and Nystatin powder to the resident’s backside. Interviews showed the pharmacy held orders for nystatin/triamcinolone every shift and econazole 1%, and the eMAR lacked the econazole order. The DON stated the facility did not receive paperwork from the dermatology clinic when the resident returned, and the ADON verified only the nystatin/triamcinolone order, not econazole. Staff L stated she should not have administered econazole without an order and should not have documented nystatin ointment when she administered the other ointment; she also stated she should not have administered nystatin powder because it had been discontinued. The ADON and ARNPs confirmed the dermatology orders included fluconazole and two ointments, with one provider identifying nystatin/triamcinolone as the first ointment and econazole as the second.
Pureed Diet Portions Were Not Measured After Blending
Penalty
Summary
The facility failed to prepare and serve pureed food to meet the nutritional needs of 2 of 3 residents reviewed, identified as Residents #17 and #28. A facility Diet Type Report dated 7/7/26 identified three residents who received a pureed texture diet. During an observation on 7/8/26 at 10:57 AM, Staff A, Cook, prepared pureed portions by placing measured amounts of beef and bean casserole, green beans, and rice with buns or tomato juice into a blender, but after blending she placed each mixture into a container for service without measuring the final product. She stated the serving sizes would be 2 #8 scoops for the beef and bean casserole and 1 #8 scoop each for the green beans and rice. During lunch service on 7/8/26 at 12:15 PM, Staff A used a #8 scoop to serve the pureed meat, vegetables, and rice to 2 of the 3 residents who received a pureed diet; Resident #6 declined lunch. In an interview later that day, the Dietary Manager stated that when preparing puree, staff always do an extra serving, add butter or sauce when blending, and should measure the final blend and use the chart to determine the correct scoop size for service. She stated Staff A should have measured the puree after blending to determine the correct serving size, but did not. A posted Care Initiatives Puree Process also directed staff to measure the total volume after pureeing and divide it by the original number of portions, and the Kitchen Weights and Measures policy stated staff would be trained in weights and measures and the appropriate serving utensil for each food.
Improper Diet Texture Served to Resident
Penalty
Summary
The facility failed to ensure staff followed dietary orders for Resident #27, who had an order for a mechanical soft texture diet. The Diet Type Report printed 7/7/26 listed the resident’s mechanical soft diet order, and the Diet Spreadsheet for Cycle Day 32 showed corn relish on the menu. The spreadsheet directed regular texture diets to receive 1/2 cup corn relish, but directed mechanical soft diets to receive 1 each puree corn instead. On 7/8/26 at 12:30 PM, Staff A, Cook, was observed serving corn relish to Resident #27 and sending the item with the meal trays to the locked unit. At 12:42 PM, the Dietary Manager observed the meal trays being distributed and found Resident #27’s tray contained corn relish. She removed the item before it was delivered to the resident and obtained another tray with the correct diet. At 12:43 PM, the Dietary Manager acknowledged the improper delivery of corn relish to Resident #27 and stated it was a mistake. At 1:22 PM, she explained the standard food preparation protocol for pureed foods, including producing an extra serving, adding butter or sauce during blending, measuring the final blend, and using a reference chart to determine scoop size. She stated Staff A failed to measure the pureed food after blending to ensure the correct serving size and that the omission was discovered too late for correction.
Incomplete and Inaccurate Clinical Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for 2 of 13 residents reviewed. For one resident with moderately impaired cognition, diabetes mellitus, and fibromyalgia, the July 2026 MAR directed Pregabalin 100 mg three times daily. The resident’s individual narcotic record contained a late entry documenting administration of Pregabalin, and a RN later reported witnessing another RN sign the first nurse’s name on the narcotic record to correct the count. The RN who signed the other nurse’s name acknowledged doing so and stated she had checked with the other nurse before leaving the shift, while the nurse whose name was signed stated the signature was not hers and that she did not give consent or instruct the other nurse to document for her. For another resident with intact cognition and diagnoses including diabetes mellitus, heart failure, and peripheral vascular disease, the MDS documented a stage three pressure ulcer and treatments. The care plan directed staff to complete ordered treatments, but review of the May and June 2026 TARs showed multiple missing entries for Betadine and offloading bandage to the left foot, daily diabetic foot checks, use of a post-op shoe, and Triad cream to the right buttocks wound. The DON acknowledged the missing documentation and stated nurses were not clicking over to the TAR from the MAR to complete documentation, and that refusals should have been documented in the EMR when they occurred.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections during medication administration for two residents. One resident had a BIMS score of 12 and diagnoses of diabetes mellitus, and the July 2026 MAR directed staff to administer Lantus insulin 25 units subcutaneously every morning and at bedtime. During a blood sugar check, an RN wore gloves, cleansed the resident’s finger, used an Assure lancet, and then threw the used lancet into the garbage can instead of a sharps container. The RN stated another nurse had told her lancets could be discarded in the garbage because they were single-use devices. The lancet box instructions directed disposal in approved sharps containers, and the DON later confirmed lancets were to be discarded in a sharps container. For the second resident, who had a BIMS score of 15 and diagnoses of diabetes mellitus and anemia, an LPN put on gloves to prepare morning medications and eye drops, touched multiple surfaces on the medication cart including the computer, medication cards, eye drop box, and pill cup, and then entered the resident’s room and administered the medications while wearing the same gloves. After leaving the room, the LPN removed the gloves and performed no hand hygiene, then pushed the medication cart to another resident’s room and documented the medication administration on the computer. The facility’s Handwashing/Hand Hygiene policy stated that hand hygiene is the primary means to prevent the spread of infection and that staff should perform hand hygiene before applying non-sterile gloves and after removing gloves; it also stated that glove use does not replace handwashing or hand hygiene.
Failure to Promote Resident Dignity and Respect
Penalty
Summary
Staff interviews and resident accounts revealed that two residents with intact cognition were not treated with dignity and respect by a registered nurse (RN) identified as Staff C. For one resident, staff reported that Staff C would yell at him, belittle him by calling him dumb, and state that she would not feel sorry for him if he fell and broke his hip. Staff also described Staff C as engaging in screaming matches with the resident, agitating him with her questions, and using wet floor signs to prevent him from standing at the nurses' station. On one occasion, Staff C reportedly tied a memory blanket to the resident's wheelchair pedals to prevent him from standing, which physically restricted his movement. Another resident reported that Staff C would keep him from returning to his room due to his attempts to use the bathroom independently and threatened to move his bed into the hallway as a form of reprimand. Staff corroborated that Staff C made such statements and described her as loud and smart-alecky, frequently yelling at the resident. The facility's policy requires that residents be treated with dignity and respect at all times, and prohibits demeaning practices, but the actions described by staff and residents indicate that these standards were not upheld for the two residents involved.
Failure to Notify Physician of Abuse Allegation
Penalty
Summary
The facility failed to notify the physician following an allegation of abuse involving a resident with severe cognitive impairment and multiple medical diagnoses, including anemia, hypertension, diabetes mellitus, thyroid disorder, traumatic brain injury, and alcohol-induced mood disorder. The resident was non-ambulatory, required substantial to maximal assistance with mobility, and was dependent on staff for locomotion in a manual wheelchair. An incident report documented that the resident was found with two dining room chairs placed behind his wheelchair in the common area to prevent tipping, which was reported as an allegation of abuse. Despite facility policy requiring immediate notification of the attending physician and medical director in such cases, there was no documentation in the incident report or the clinical record that the physician was notified at the time of the incident. Interviews with the DON and Administrator confirmed that the physician was not notified until several days later due to miscommunication and the suspension of the ADON. The delay in physician notification was acknowledged by facility leadership, and the required documentation was not present until after the incident had already occurred.
Unauthorized Use of Physical Restraints on Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including traumatic brain injury and alcohol-induced mood disorder, was subjected to the use of physical restraints. The resident, who was non-ambulatory and dependent on staff for mobility and transfers, was identified as being at risk for falls and required to be within line of sight of staff at all times. Despite this, staff placed two dining room chairs behind the resident's wheelchair while he was seated at a dining room table in the common area, restricting his ability to move his wheelchair backward. Multiple staff members observed the chairs positioned behind the resident's wheelchair on several occasions, with some staff removing the chairs when they noticed them. Staff interviews revealed that the chairs were placed to prevent the resident from standing up or moving backward, as staff were unable to provide constant supervision. The resident was also pushed up to the table with his chest almost touching it, and the wheelchair was locked, further limiting his movement. Staff acknowledged that the chairs were used as a means to control the resident's mobility due to staffing constraints and the resident's tendency to attempt standing. Facility policy prohibits the use of physical restraints except for medical treatment and only after other alternatives have been tried unsuccessfully. The policy also defines physical restraint as any method that restricts a resident's freedom of movement and cannot be easily removed by the resident. The use of chairs to block the resident's wheelchair was not authorized, not medically indicated, and was implemented for staff convenience rather than the resident's safety or medical need, constituting a violation of the facility's restraint policy.
Failure to Timely Report Alleged Abuse and Notify Authorities
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a resident who was found in a wheelchair with two dining room chairs placed behind it, preventing backward movement. The Maintenance Supervisor discovered the situation early in the morning and immediately removed the chairs, then notified the Dietary Manager. The concern was brought up at a quality assurance meeting later that morning and reported to the Assistant Director of Nursing (ADON), who acknowledged awareness but did not escalate the issue. The Administrator was not present at the meeting and was not informed until the following day, after which the incident was reported to the Department of Inspection, Appeals and Licensing (DIAL) more than a day after the initial observation. The facility also failed to notify law enforcement of the abuse allegation, as required by policy. Staff interviews revealed that the incident was not recognized or reported as abuse in a timely manner, and the facility's own policy required immediate reporting to state authorities and law enforcement. The delay in reporting and lack of immediate action by responsible staff contributed to the deficiency, as the incident was not addressed according to regulatory and facility policy requirements.
Failure to Immediately Separate Staff Accused of Abuse
Penalty
Summary
The facility failed to immediately separate a staff member accused of alleged abuse from contact with dependent residents. On the morning of 11/19/25, a maintenance supervisor observed a resident in a wheelchair with two dining room chairs placed behind the wheelchair, restricting the resident's ability to move backward. The maintenance supervisor reported the concern to the Assistant Director of Nursing (ADON) during a Quality Assurance meeting later that morning. The ADON acknowledged the concern but did not notify the Administrator, initiate an investigation, or separate the accused staff member from residents. As a result, the staff member continued to work full shifts on both 11/19/25 and 11/20/25. The incident was not reported to the Administrator until the afternoon of 11/20/25, after which the Administrator learned that the staff member had not been suspended or separated from residents. Facility policy requires that any employee accused of resident abuse be placed on leave with no resident contact until the investigation is complete. The failure to follow this policy resulted in the accused staff member maintaining resident contact for nearly two days after the initial allegation was made.
Failure to Correct Deficiency in Sufficient Nursing Staff
Penalty
Summary
The facility failed to correct previously identified deficiencies related to sufficient nursing staff, as evidenced by repeated concerns noted in both the current and past surveys. The QAPI program, revised in March 2020, is overseen by the QAPI committee and ultimately the Administrator, who is responsible for interpreting findings to the governing body. Despite this structure, the facility did not address ongoing issues with call light response times, which were brought up by residents during surveyor interviews but not reported to staff. The Administrator acknowledged that residents communicated their concerns about call lights to surveyors rather than staff, and that staff did not perceive or report these issues themselves. The Administrator indicated that call light audits had been conducted within the last year, but deficiencies related to staffing persisted, primarily based on resident interviews rather than direct observation. The Administrator also expressed the belief that staff would never feel they had enough help, and that increased staffing did not necessarily improve efficiency or outcomes. These statements and the lack of effective corrective action contributed to the facility's failure to resolve the deficiency regarding sufficient nursing staff.
Failure to Provide Sufficient Nursing Staff for Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents in a timely manner, as evidenced by clinical record reviews, PBJ data, and multiple staff and resident interviews. One resident with intact cognition reported that call light response times could take 30 to 45 minutes or longer, and that staff sometimes turned off the call light without returning. Facility records and resident council documentation confirmed call light response times between 15 and 30 minutes. PBJ data reflected excessively low staffing on weekends, and staff interviews described frequent situations where only one nurse and one CNA were responsible for nearly 40 residents. Staff also reported that management did not assist with direct care during shortages, and that staff were often required to find their own replacements when calling in absent. Staff described being mentally and physically exhausted due to chronic understaffing, particularly during evening and weekend shifts. They reported difficulty completing essential care tasks, such as resident baths, and managing increased resident needs during high-activity periods like bedtime. The DON acknowledged that the facility's policy expected call lights to be answered within 15 minutes, but described ongoing challenges in maintaining adequate staffing levels, especially after hours and on weekends. The facility's own grievance documentation and staff interviews consistently indicated that staffing levels were insufficient to provide timely care to all residents.
Failure to Provide SNFABN Form Upon Discharge from Medicare Coverage
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNFABN) form to two residents whose Medicare Part A skilled stay ended and who continued to reside in the facility under private pay. Clinical record reviews for both residents showed no documentation that the SNFABN form was given to either the residents or their representatives at the time of discharge from Medicare coverage. Staff interviews confirmed that the necessary forms could not be located for these residents. Both residents had severely impaired cognition as indicated by their Brief Interview for Mental Status (BIMS) scores. One resident had diagnoses including hypertension, cerebrovascular accident, aphasia, and dysphagia, and was using a feeding tube. The other resident had diagnoses of pneumonia, urinary tract infection, depression, coronary artery disease, and hypertension. Despite facility policy requiring advance written notice of potential liability for non-covered services, the required notification was not documented for either resident.
Lack of Physician Orders for Feeding Tube Water Flushes During Medication Administration
Penalty
Summary
The facility failed to have physician orders specifying the amount of water to flush a feeding tube when administering medications for a resident with a feeding tube. The resident in question had a history of traumatic brain injury, subdural hemorrhage, altered mental status, persistent vegetative state, and dysphasia, and was dependent on staff for mobility and transfers. The resident's care plan indicated tube feeding with specific instructions to check tube placement and gastric residuals per facility protocol, but there was no documented order for the amount of water to use for flushing during medication administration. Observations and interviews revealed that nursing staff administered medications via the resident's feeding tube using water flushes based on facility protocol, but without a specific physician order for the water amount. Staff reported using 30 mL of water to dissolve medications and additional flushes before, between, and after medication administration, following the facility's policy. However, the policies themselves were outdated, and staff could not locate them at the nurses' station or on the medication cart. The Director of Nursing (DON) and Corporate Nurse acknowledged that staff were expected to follow the policy, but there was no documentation of physician orders for water flush amounts or of staff education on the policy. Additionally, there was inconsistency in practice regarding checking for gastric residuals and tube placement, with staff reporting changes to their routine only after being questioned by surveyors. The DON stated that the physician had previously indicated residual checks were not required, but there was no documentation to support this. The lack of clear, accessible policies and specific physician orders for water flushes during medication administration led to the deficiency identified by surveyors.
Failure to Replace and Clean Nebulizer Equipment as Required
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a history of hypertension, cerebrovascular accident, aphasia, and dysphagia was found to have a nebulizer mask and tubing at the bedside that had not been changed since it was dated several months prior. The nebulizer mask was visibly dirty, with dust particles and dried liquid spots present. Observations confirmed that the equipment remained at the bedside over multiple days, and the mask/chamber was still marked with the old date. Record review showed that the resident had not received nebulizer treatments for several months, with the last documented use occurring in January, and the order for nebulizer treatments had been discontinued in February. Despite this, the equipment was not removed or cleaned according to facility policy, which required weekly replacement and nightly cleaning of the nebulizer apparatus. Staff acknowledged the outdated and unclean equipment during the survey and confirmed that the expected practice was not followed.
Failure to Follow Infection Control Protocols During Device Care and Medication Administration
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections, particularly for a resident with a feeding tube and during medication administration for two other residents. For the resident with a feeding tube, staff did not follow enhanced barrier precautions (EBP) as required. During a dressing change to the gastrostomy tube (g-tube) site, the LPN did not wear a gown as directed by EBP protocols, used the same pair of gloves throughout the procedure without changing them between dirty and clean tasks, and did not perform hand hygiene at appropriate intervals. The staff member acknowledged these lapses and confirmed awareness of the correct procedures, including the need to change gloves and perform hand hygiene between steps. Additionally, during medication administration for two residents, a Certified Medication Aide (CMA) failed to perform proper hand hygiene and gloving practices. The CMA did not sanitize hands after glove removal, between residents, or before entering a resident's room. The CMA also placed an eye drop bottle directly on a resident's bedside table without a barrier and carried used gloves from the resident's room to the medication cart before discarding them. These actions were contrary to facility policies and CDC guidelines, which require hand hygiene before and after resident care, after glove removal, and when moving between residents or care tasks. Facility policies reviewed included requirements for EBP, handwashing, and glove use, all of which were not followed during the observed incidents. The Director of Nursing confirmed the expectation that staff adhere to these protocols, including wearing gowns for high-contact activities involving medical devices, changing gloves, and performing hand hygiene at appropriate times. The observed failures represent a breakdown in infection prevention and control practices as outlined in facility policy.
Failure to Timely Assess and Document Resident Injury After Assisted Fall
Penalty
Summary
A deficiency occurred when staff failed to immediately assess and document appropriate interventions for a resident who was lowered to the floor and sustained an abrasion to her back. The resident, who had intact cognition and required substantial to maximal assistance with mobility and transfers, attempted to self-transfer from the toilet to her wheelchair. During this attempt, her knees buckled and a CNA assisted her to the floor to prevent a fall, resulting in a back abrasion. The CNA observed bleeding skin tears and attempted to notify the nurse, but there was a significant delay in the nurse's response. Multiple staff interviews confirmed that the nurse did not promptly respond to the incident, with reports indicating a wait time of 10 to 40 minutes before the nurse arrived to assess the resident. During this period, CNAs moved the resident from the floor to her wheelchair without a nursing assessment. The nurse, when she did arrive, did not immediately assess the resident's back injury and later admitted to forgetting to complete the assessment after the resident was put to bed. The initial documentation and assessment of the abrasion did not occur until the following day, despite the injury being visible and reported at the time of the incident. The resident's clinical record indicated a history of falls and multiple diagnoses, including hypertension, diabetes, and mental health conditions. Despite these risk factors and the facility's policy requiring immediate assessment after incidents or changes in condition, the required head-to-toe assessment and documentation were not completed in a timely manner. The delay in assessment and failure to follow protocol were acknowledged by the Director of Nursing and confirmed through staff interviews and record review.
Failure to Prevent Accidents and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure the safety and adequate supervision of two residents, resulting in deficiencies related to accident hazards and fall prevention. One resident, who had intact cognition but significant physical limitations and a history of falls, required assistance from two staff members and the use of a standing mechanical lift for all transfers, including toileting. Despite these requirements being clearly documented in the care plan and CNA Kardex, a staff member left the resident unattended in the bathroom after assisting with toileting and peri-care, stepping out to seek help for the transfer. During this absence, the resident attempted to self-transfer from the toilet to the wheelchair, resulting in her knees giving out and the staff member having to lower her to the floor. The resident sustained abrasions to her back during this incident. Interviews and documentation revealed that the staff member was aware of the resident's need for two-person assistance but proceeded to stand the resident up alone for peri-care and left her unsupervised in the bathroom. There was also a significant delay in the nurse's response to the incident, as the nurse prioritized completing a medication pass before assessing the resident. The nurse did not immediately assess the resident's injuries, and the required assessment of the resident's back was not completed until the following day. Staff interviews confirmed that the care plan was not followed, and the nurse did not respond promptly to the fall, leaving the resident on the floor for an extended period before being assisted back to her wheelchair. In a separate incident, another resident with moderate cognitive impairment and a history of falls was found on the floor after attempting to transfer from a wheelchair to bed and experiencing dizziness. The care plan for this resident did not include any new interventions following the fall, despite facility policy requiring investigation and implementation of preventive measures after such events. The Director of Nursing acknowledged the lack of intervention and documentation for this incident, which was inconsistent with facility policy and expectations for fall prevention and resident safety.
Resident's Dignity Compromised by Inappropriate Staff Interaction
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as required by regulations, which was identified during a survey. The resident, who had intact cognition and was dependent on staff for certain activities, reported feeling uncomfortable with the behavior of a Certified Nursing Assistant (CNA). The resident expressed that the CNA often joked in a manner that was not appreciated, specifically mentioning an incident where the CNA questioned the resident's ability to remove their own socks. Although the resident did not feel degraded, they expressed a desire for the joking to stop and to be treated with dignity and respect. The facility's Administrator confirmed that staff are expected to treat residents with dignity and respect at all times. The resident's care plan included interventions to support their emotional and social needs, such as conversing with the resident during care and monitoring their feelings of sadness, anxiety, and depression. Despite these measures, the resident's experience with the CNA did not align with the facility's expectations or the resident's rights to a dignified existence and self-determination, as outlined in the Residents' Rights document.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure that staff responded to resident call lights and needs in a timely manner, specifically within fifteen minutes, as required. This deficiency was identified through interviews with three residents, all of whom reported waiting longer than the expected time for assistance. Resident #2, who has intact cognition and requires total assistance for various activities of daily living, frequently experienced delays in response times, which he tracked using his watch. Similarly, Resident #33, also with intact cognition and requiring maximal assistance, reported waiting over fifteen minutes for staff to respond, using a wall clock to verify the delay. Resident #87, with intact cognition and medical conditions including hemiplegia and chronic obstructive pulmonary disease, also reported waiting longer than fifteen minutes for assistance, confirmed by checking his watch. The Director of Nursing acknowledged the expectation for staff to respond within fifteen minutes, aligning with the facility's policy revised in March 2021, which aims to ensure timely responses to residents' requests and needs. Despite this policy, the facility's failure to meet the response time requirement was evident in the experiences of the interviewed residents.
Failure to Maintain Sanitary Conditions During Meal Service
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions, as observed during a noon meal service. Staff A, a cook, did not perform hand hygiene before applying gloves and began preparing and serving the meal. Staff A touched various items, including plates, utensils, serving pans, and paper menus, without changing gloves or completing hand hygiene. Additionally, Staff A reached into a bread sack with the same gloves, placed bread on a plate, added meat, and used a knife to cut the sandwich. The cook continued to handle food with soiled gloves, touching meat and bread to add mashed potatoes. After removing gloves to get a cup of butter and barbeque sauce, Staff A washed hands and applied new gloves but continued to serve the meal while touching various items with gloved hands. The facility's Food Preparation and Service policy, revised in April 2019, requires staff to wash hands before serving food, after collecting soiled plates, and to change gloves between tasks.
Failure to Implement Restorative Nursing Program for Resident
Penalty
Summary
The facility failed to complete necessary assessments for a resident, identified as Resident #26, to determine if his abilities remained unchanged or had declined. Resident #26 had impairments on both sides of his upper and lower extremities, yet did not have a restorative nursing program in place. The Minimum Data Set (MDS) indicated a progression of impairment from one side to both sides of his extremities. Despite recommendations from therapy for a Restorative Nursing Program (RNP), the facility did not implement such a program, and the care plan lacked documentation of restorative nursing interventions. Interviews with the Director of Nursing (DON), MDS Coordinator, and the Administrator revealed that the facility did not have an active restorative program due to low participation. The Occupational Therapist confirmed that an RNP was written upon Resident #26's discharge from therapy, but it was not effectively communicated or documented in the resident's care plan. The facility's policy on Restorative Nursing Services, revised in July 2017, directed the provision of restorative care to promote safety and independence, but this was not adhered to in Resident #26's case.
Failure to Change and Label Oxygen Tubing
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not changing and labeling oxygen tubing as required. Resident #87, who had been admitted to the facility and had a hospitalization before returning, was observed with unlabeled oxygen tubing lying on the floor. The facility's Medication Administration Record/Treatment Administration Record (MAR/TAR) did not include a weekly order to change the oxygen tubing, which was a requirement for infection control. The Director of Nursing (DON) acknowledged that the tubing should have been labeled and documented in the MAR/TAR, but it was not. The DON stated that the facility's practice was to change oxygen tubing every Sunday, but there was no documentation to support that this was done for Resident #87. The resident reported that the tubing had not been changed since their admission. The facility's Oxygen Administration policy required documentation of the procedure, including the date, time, and individual performing the procedure, as well as the rate of oxygen flow and how the resident tolerated the procedure. This documentation was missing, leading to the deficiency noted by the surveyors.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure that resident call lights were answered and resident needs were met in a timely manner, specifically within fifteen minutes, for three residents. Resident #1, with intact cognition and requiring total assistance for transfers, bed mobility, dressing, and toilet use, reported frequent delays in call light responses, which he tracked using his watch. Similarly, Resident #3, also with intact cognition and dependent on staff for similar needs, experienced delays and monitored the time using a wall clock. Resident #7, who required assistance for transfers, bed mobility, dressing, and toilet use, reported waiting longer than fifteen minutes at least once a day, using a wall clock to track the time. Staff interviews revealed inconsistencies in staffing levels, affecting the timeliness of call light responses. Staff I indicated that staffing adequacy varied daily, depending on call-ins. Staff J and K noted improvements in staffing but acknowledged previous shortages on four out of seven days. Staff L expressed concerns about insufficient staffing to meet call light response expectations. The Assistant Director of Nursing (ADON) confirmed the expectation for staff to respond to call lights within fifteen minutes and to seek assistance if unable to fulfill a resident's request. The facility's policy on answering call lights, revised in March 2021, outlined procedures to ensure timely responses, including demonstrating call light use to residents and ensuring call lights are functional and within reach.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 141 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stratford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grandview Health Care Center | 5.4 mi | ★★★★★ | 9 | 0 |
| Eastern Star Masonic Home | 14.6 mi | ★★★★★ | 11 | 0 |
| Westhaven Community | 14.6 mi | ★★★★★ | 15 | 0 |
| Crestview Nursing And Rehabilitation | 14.7 mi | ★★★★★ | 13 | 0 |
| Southfield Wellness Community | 14.8 mi | ★★★★★ | 29 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.