Stratford Pines Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Stratford Pines Nursing and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 4, 2024

  This citation pertains to intake # MI00148110 Based on interview and record review, the facility failed to provide increased supervision for 1 of 5 resident's (Resident #1) reviewed for falls, resulting in a fall with neck fractures and subsequent death. Findings: Resident #1 (R1) Review of an Admission Record revealed R1 was an [AGE] year-old male, admitted to the facility on [DATE], following a 13-day hospital stay for a left broken femur and multiple fractures of the pelvis. Other relevant diagnoses included highly impaired vision, hard of hearing, and chronic kidney disease. […]

• Actual harm, isolatedF686Nov 30, 2023

  Based on observation, interview, and record review, the facility failed to monitor and prevent the development and worsening of pressure sores for one Resident (R39) of four reviewed for pressure sores, resulting in undocumented monitoring and worsening of pressure sores and increased pain. Findings: The Minimum Data Set (MDS) dated [DATE] reflected R39 admitted to the facility 10/12/23 with diagnoses that included Heart Failure and Renal Insufficiency. The MDS section M, Skin Conditions, reflected R39 was at risk for developing pressure sores but had no pressure sores at the time of admission. The Electronic Medical Record (EMR) document titled Wound Measurement dated 11/11/23 at 11:50 AM reflected that two new pressure wounds were identified on the right and left buttocks of R39. […]

• Actual harm, isolatedF684Jun 17, 2021

  This citation is related to intake # MI00- 7 Based on interview and record review, the facility failed to provide quality coordinated care to prevent a fall for 1 resident (Resident #117), resulting in bruising of the face, jaw, and neck and a left periorbital soft tissue hematoma ( a blood clot on the left side of the face, around the left eye) that required immediate emergency medical treatment and eventually required an incision and drainage (surgical procedure to remove the large blood clot and dead tissue). Findings: Resident #117 (R117) Review of an Admission Record revealed R117 was an [AGE] year old female, admitted to the facility the evening of Friday 1/19/21, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Nov 22, 2022

  Based on observation, interview and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting all residents who receive meal services out of the facility's total census of 73 residents. Findings include: 1. On 11/15/2022 at 11:33 AM, the juice machine's dispensing gun supplying thickened liquids was observed with visible dried thickened liquid on the interior and exterior of its nozzle. […]

• No harm, potential for more than minimal, widespreadF812Jun 17, 2021

  Based on observation, interview, and record review, the facility failed to maintain clean food-contact and nonfood-contact surfaces resulting in the potential for cross contamination of equipment and spread of foodborne disease. The deficient practice affects all 71 residents who consume food from the kitchen. Findings include: On 6/15/21 at 11:07 AM, during an inspection of the kitchen, assisted by Director of Nutritional Services (DNS) B, a blue plastic bag was observed to be covering the commercial stand-up mixer. Upon further inspection, dried food debris was observed on the splash guard of the commercial stand-up mixer. […]