Stamford Care Center

In the surveyor’s words

From the most serious findings on record at Stamford Care Center, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 10, 2026

  Based on observations, interviews, clinical record, and policy reviews for 1 of 3 sampled residents (Resident #23) reviewed for pressure ulcers, the facility failed to provide services to prevent worsening of 2 pressure wounds for a dependent resident. The findings include:Resident #23's diagnoses included open wound of the lower back and pelvis, quadriplegia (paralysis affecting all 4 limbs and the torso), and malnutrition.The comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 had a Brief Interview of Mental Status of 00 indicating severe cognitive impairment and was totally dependent on staff for toileting, transfers, and changing positions in bed (rolling, lying and sitting). […]

• Actual harm, isolatedF689Jun 2, 2025

  Based on clinical record reviews, facility documentation, and staff interviews for one (1) of three (3) sampled residents (Resident #1) who required staff assistance with personal hygiene, the facility failed to ensure the resident was positioned safely in the bed and the correct number of staff assistance were present in accordance with the care plan prior to adjusting the height of the bed to prevent the resident from sliding out of the bed. The findings include: Resident #1's diagnoses included hemiplegia, hemiparesis, vascular dementia, aphasia, cerebrovascular disease, disorder of bone density and structure. […]

• No harm, potential for more than minimal, patternF584Feb 10, 2026

  Based on observations, interviews, facility documentation, and facility policy, the facility failed to provide safe and comfortable air temperature levels in resident rooms and common areas. The findings include: During an initial tour of the facility, observation and interview with Licensed Practical Nurse (LPN) #5 on 2/8/26 at 7:02 AM, identified the 1st Floor East hallway air temperature was noted to be cold. LPN #5 was dressed in a winter hat, 2 sweaters, and a scarf. LPN #5 stated that it's freezing on the 1st floor and is always like this at night. Observation and interview on 2/8/26 at 7:11 AM with Resident #52 identified him/her in bed, covered with 3 blankets, and the facility heating system in the room was running at the highest possible setting. […]

• No harm, potential for more than minimal, patternF804Feb 10, 2026

  Based on interviews, a sample test tray, facility documentation, and policy, the facility failed to provide appetizing and palatable food. The findings include:Review of the Resident Council Minutes dated 9/26/25 identified Resident concerns that meat was not tender and hard to chew (there was no response noted from the Dietary Department).Review of the Resident Council Minutes dated 11/21/25 identified Resident concerns that food was delivered cold, and the meat was not tender (there was no response noted from the Dietary Department).Review of the Resident Council Minutes dated 12/24/25 identified Resident concerns about the pork being overcooked, the facility response from the Dietary Food Director was to speak to the cooks regarding overcooking protein.Review of Resident Council minutes… […]

• No harm, potential for more than minimal, patternF809Feb 10, 2026

  Based on interviews, observations, and facility documentation, the facility failed to provide meals at regularly scheduled intervals. The findings include:Review of the Resident Council Minutes dated 10/27/25 identified Resident concerns that food trucks were late to some of the units. (there was no response noted from the Dietary Department).Review of the Resident Council Minutes dated 11/21/25 identified Resident concerns that food took too long to be delivered and was cold (there was no response noted from the Dietary Department).Review of the Resident Council Minutes dated 12/24/25 identified Resident concerns with the food trucks, and food not being passed out when it reached the unit destination (there was no response from the facility).Review of Resident Council minutes dated… […]