Stratford Villa Post-Acute

In the surveyor’s words

From the most serious findings on record at Stratford Villa Post-Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Nov 7, 2023

  Based on observation, interview, and record review, for one of four sampled residents (Resident 1), the facility failed to ensure staff provide immediate life-saving measures (cardiopulmonary resuscitation [CPR] - rescue breathing and or chest compressions when the heart stops) when Resident 1 was found in bed without vital signs (Vs, temperature, pulse, respirations, blood pressure ). Resident 1 was a full code (desired all medical emergency interventions when breathing and or heart stops). Licensed Vocational Nurse (LVN) 2 declared Resident 1 expired (dead) and did not initiate CPR or call emergency personnel ([DATE]). This failure of LVN 2 to provide CPR and call emergency personnel was determined to constitute an Immediate Jeopardy (IJ). […]

• Actual harm, isolatedF684Nov 7, 2023

  Based on interviews and record review, the facility failed to perform a proficient neurological assessment (a series of questions and or motor tests in the event of a sudden change in condition to detect neurological changes: level of consciousness, orientation, movement of arms and legs, pupil size and reaction to light) for one (Resident 1). Staff did not maintain monitoring according to professional standards to detect early changes that required emergent medical treatment after Resident 1 sustained an unwitnessed fall. This failure resulted in not identifying a change in Resident 1 ' s neurological status. […]

• Actual harm, isolatedF842Nov 7, 2023

  Based on interview and record review, the facility failed to ensure Resident 1 ' s admission record showed all diagnoses from the hospital were included in Resident 1's admission record to the facility. This deficient practice resulted in the incomplete and inaccurate history of medical diagnoses that prevented Resident 1 from receiving comprehensive and anticipatory care. On [DATE], Resident 1 suffered an unwitnessed fall in the facility and expired (died ) in the facility on [DATE]. Findings: A review of Resident 1 ' s hospital records titled, Physician Hospitalist Discharge and Transfer Instruction (PHDTI), dated [DATE], indicated Resident 1 was admitted to the hospital due to a fall at home. […]

• No harm, potential for more than minimal, widespreadF801Mar 21, 2024

  Based on observation, interview, and record review, the facility failed to ensure state requirements were met for a full-time registered dietitian or the person designated to serve as the director of food and nutrition services was hired on staff on a full-time basis (35+hours/week). This failure had the potential for food and nutrition services staff to be inadequately trained and supervised to carry out food and nutrition services for 26 out of 26 residents. Findings: During an interview on 3/19/24 at 8:39 a.m., with the Dietary Supervisor (DS) and Registered Dietician (RD), DS stated he did not work full time in the Kitchen. DS said he also worked next door at the sister facility. DS further stated he provided dietary staff training and checked their competencies. […]

• No harm, potential for more than minimal, widespreadF812Mar 21, 2024

  Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when: 1. Hand washing sink was located right next to coffee machine and beverage dispenser. 2. Multiple food items opened with no use-by dates; bag of permecian gravy opened 3/5/24, bag of chicken gravy mix opened 3/2/24, carton of lactose free milk opened 3/12/24, cartoon of pineapple juice opened 3/10/24. There were five pounds of Monterey jack cheese opened 3/11/24, and a plastic container of apple sauce, dated 3/10/24. 3. Three-compartment sink was not operated according to instructions. 4. Ice machine had brownish whitish hard sticky substance on the right area on the outside difficult to wipe off. 5. […]