Stratford Specialty Care

In the surveyor’s words

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

• Immediate jeopardy, isolatedF580Feb 7, 2023

  Based on clinical record review, facility policy review, provider guidelines, staff, and nurse practitioner interview the facility failed to notify the provider on a resident that had a decline in condition after a fall on 9/3/23, for which the resident started to present with changes in altered mental status, unstable vital signs, and vomiting. The resident passed away at the facility on 9/5/22. (Resident #1). This failure put the facility into an Immediate Jeopardy to the health, safety, and security of the resident. The facility also failed to notify a provider of a resident that contacted the Suicide Hotline and required 1-1 supervision. (Resident #9). […]

• Immediate jeopardy, isolatedF689Oct 6, 2022

  Based on observations, clinical record reviews, employee time card reviews, facility policies reviews, and staff interviews, the facility to provide appropriate education related to the sounds of the door alarms to ensure safety for one of three residents reviewed (Resident #1). Interviews determined that the staff reported that they could not hear the alarms or they heard the alarms but did not know what the sound meant. In the afternoon of 9/5/22, Resident #1 became anxious after becoming incontinent. Some of the staff reported that Resident #1 turned on his call light but when no one answered it, he exited the facility through the left, or west, exit door. […]

• Actual harm, isolatedF684Aug 29, 2022

  Based on observations, facility policies reviews, clinical record reviews, staff, and physician interviews the facility failed to appropriately provide assessment and interventions for the necessary care and services related to a change in condition for one of five residents reviewed (Resident #11). The facility failed to address Resident #11's weight after a 12 pound weight gain in three weeks with abnormal lab values. Despite the provider visiting Resident #11 multiple times, the increase of weight failed to get assessed. At the time of Resident #11's admission to the hospital on 8/18/22 he did not have a weight for over a month. […]

• No harm, potential for more than minimal, widespreadF865May 21, 2025

  Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facility's past surveys, and staff interview, the facility failed to correct their own deficiencies for 1 of concern. The facility reported a census of 36 residents. Findings include: The Quality Assurance and Performance Improvement (QAPI) Program revised March 2020 is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the Administrator and governing body. The Administrator, whether a member of the QAPI Committee or not, is ultimately responsible for the QAPI program and for interpreting its results and findings to the governing body. […]

• No harm, potential for more than minimal, patternF607Jul 9, 2026

  Based on personnel record review, staff interview and policy review the facility failed to provide appropriate screening prior to employment for 1 of 5 employees reviewed for background checks. The facility reported a census of 39 residents. Findings include:The personnel file for Staff D, (Registered Nurse) documented a start date of 6/24/25. The personnel file lacked documentation that a Single Contact License and Background Check (SING) was completed prior to hire. Review of current nursing schedules revealed Staff D was an active RN at the facility and was working during the survey. On 7/8/26 at 4:30 PM, the Administrator reported the facility could not locate the SING for Staff D. […]