Heritage Manor of Stratmore Nursing & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Heritage Manor of Stratmore Nursing & Rehab CTR, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 8, 2022

  Based on interviews and record reviews, the facility failed to ensure a resident was free from accidents hazards during a transfer for 1 (#1) of 5 (#1, #2, #3, #4, and #5) sampled residents who required two-person transfer with a mechanical lift. This deficient practice resulted in an actual harm for Resident #1 on [DATE] at 10:20 a.m., when S2CNA (Certified Nurse Assistance) transferred the resident from bed to chair without assistance of another person and without using the mechanical lift. S2CNA slipped and fell causing Resident #1 to fall with her during a manual transfer. Resident #1 was transferred to the hospital on [DATE] and diagnosed with bilateral closed proximal tibial fractures and expired on [DATE] at 8:00pm. […]

• No harm, potential for more than minimal, patternF605May 20, 2026

  Based on record review and interview, the facility failed to ensure a resident with an order for a psychotropic medication was not subjected to chemical restraints for 1 (#11) of 1 resident reviewed for hospice. The facility failed to ensure Resident #11's order for a psychotropic medication was limited to 14 days. Findings: Review of Resident #11's medical record, revealed Resident #11 was admitted on [DATE] with diagnoses including generalized anxiety and bipolar disorder. Review of Resident #11's physician orders revealed in part, an order dated 12/24/2025 for lorazepam 0.5 ml every 2 hours as needed for anxiety and restlessness related to generalized anxiety disorder. Further review of Resident #11's PRN lorazepam order failed to reveal a stop date or rational for continued use. […]

• No harm, potential for more than minimal, patternF656May 20, 2026

  Based on record reviews and interviews, the facility failed to develop and implement an individuaized comprehensive care plan to maintain a residents highest practicable physical, mental and psychosocial well-being for 2 (#11, #65) of 2 residents reviewed. The facility failed to develop fall interventions for Resident #11 and implement restorative services for Resident #65.Findings:Resident #11Review of Resident #11's medical record revealed an admit date of 01/31/2022 with the following diagnoses including in part: Parkinson's disease, dementia, and generalized anxiety.Review of Resident #11's medical record for the past six months revealed Resident #11 had a fall on 12/15/2025, 01/08/2026, 01/26/2026, 03/09/2026, 04/02/2026, 04/03/2026, 04/12/2026, 04/13/2026 and 05/04/2026. […]

• No harm, potential for more than minimal, patternF686May 20, 2026

  Based on record review, observation and interviews, the facility failed to ensure 1 (#99) of 1 resident reviewed for skin conditions received treatment and services to prevent an infection and new wounds from developing. The facility failed to assess Resident #99's skin during and following heat therapy resulting in a burn.Findings:Review of Resident #99's medical record revealed an admit date of 12/13/2023 with the following diagnoses, including in part: type 2 diabetes mellitus with other circulatory problems and diabetic peripheral angiopathy without gangrene, peripheral vascular disease, unspecified open wound lower leg initial encounter, vitamin deficiency unspecified, edema unspecified anesthesia of skin, other soft tissue disorders, other skin changes, venous insufficiency (chronic)… […]

• No harm, potential for more than minimal, patternF690May 20, 2026

  Based on record review and interviews, the facility failed to ensure a resident's indwelling urinary catheter was flushed with normal saline every shift according to physician's orders for 1 (Resident #94) of 2 sampled residents reviewed for catheter use. Findings: Review of Resident #94's medical record revealed an admit date of 05/07/2025 with a diagnosis in part of neuromuscular dysfunction of the bladder. Review of Resident #94's physician orders revealed in part an order dated 06/17/2025: Flush catheter with normal saline every shift. Review of Resident #94's medical record failed to reveal documentation Resident #94's indwelling urinary catheter had been flushed every shift with normal saline as ordered for the month of May, 2026. […]