Stratford Commons Rehab & Health Care Center

In the surveyor’s words

From the most serious findings on record at Stratford Commons Rehab & Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 18, 2025

  The facility identified a census of 53 residents, with three residents sampled for elopement risk. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent newly admitted Resident (R) 1, who had documented intermittent confusion and exit-seeking/wandering behaviors, from leaving the facility on 10/18/25 between 05:20 AM and 05:30 AM, without staff knowledge. R1 remained outside of the facility (whereabouts unknown) for approximately five and a half hours, wearing only a hospital gown and no shoes, in approximately 65 degrees Fahrenheit temperature. Law enforcement located R1 at 10:50 AM, approximately one mile from the facility, wearing a hospital gown and no shoes. […]

• No harm, potential for more than minimal, widespreadF838Feb 8, 2024

  The facility identified a census of 54 residents. Based on observation, record review, and interviews, the facility failed to conduct a thorough, updated facility-wide assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 54 residents residing in the facility. Findings included: - A review of the Facility assessment dated [DATE] provided by the facility revealed the assessment listed the number and types of admissions for the past year to date. The assessment sections were not completed in the sections that documented the staffing level, competencies required, equipment, and physical or environmental needs to address the facility's specific resident population and acuity. […]

• No harm, potential for more than minimal, widespreadF880Feb 8, 2024

  The facility identified a census of 54 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to the implementation of procedures to monitor and prevent Legionella disease (Legionella is a bacterium that can cause pneumonia in vulnerable populations) or other opportunistic waterborne pathogens and failed to ensure sanitary storage of respiratory equipment. These deficient practices placed the residents at risk for complications related to infectious diseases. Findings included: - Observation on 02/07/24 at 08:33 AM Certified Nurse Aide (CNA) N pushed R29 in the wheelchair into R29's room and stepped onto the nasal cannula on the floor as she pulled the bedding down on R29's bed. […]

• No harm, potential for more than minimal, widespreadF881Jul 28, 2022

  The facility reported a census of 55 residents. Based on interview and record review, the facility failed to ensure principles of antibiotic stewardship were followed to ensure antibiotics were used in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance in an ongoing, proactive manner. Findings included: - Review of the Infection Control Log for tracking and trending infections from January 2022 through June 2022, revealed the following: January, February and March logs lacked documentation of organism identifications for monitoring trends in infection. The May 2022 log was not done/unavailable for review. The Infection Preventionist (IP) was not available to interview. […]

• No harm, potential for more than minimal, patternF761Nov 17, 2025

  The facility had a census of 57 residents. The facility had six medication carts and two medication rooms. Based on observation, interview, and record review, the facility failed to remove outdated or expired medication from potential administration to residents.Findings included:- On 09/29/25 at 07:42 AM, the Blue Medication cart contained two expired medications:Heartburn relief liquid antacid, 12 fluid ounces, with the expiration date of 10/2024. Vitamin D3, 50 micrograms (mcg), bottle of soft gels, expired April 2023.On 09/30/25 at 09:00 AM, the Blue medication room had an emergency kit box with two vials of Ativan (antianxiety drug) with an expiration date of 07/2024. On 09/29/25 at 07:45 AM, Certified Medication Aide (CMA) S verified the expiration dates on the medications. […]