Stratford Villa Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure for two out of four residents (Resident 1 and 2), that their rights were protected, when facility did not verify the informed consents were obtained from the responsible party, and informed consent were not in Resident 1 and 2's medical records. These failures resulted in violating the residents' right to be informed with their medical treatment.Cross reference to F 684Findings:A review of Resident 1's admission Record (AR) indicated Resident 1 was admitted on [DATE] with diagnoses that included Parkinson's Disease without dyskinesia, without mention of fluctuations. Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 11/08/2025 indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 05 (BIMS score of 00 - 07: severe impairment; 08 - 12: moderately impaired; and 13 - 15:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure for two out of four residents (Residents 1 and 2), Residents 1 and 2 receive treatments according to their needs. Residents 1 and 2 were treated with brain mapping/neurofeedback treatment (a biofeedback, which teaches self-control of brain functions to subjects by measuring brain waves and providing a feedback signal. Neurofeedback usually provides audio and/or video feedback), without after treatment plan and care provided. These failures had potential to affect Residents 1 and 2's health and safety due to lack of care coordination.Cross reference to F 578Findings:1. During a review of Resident 1's admission Record (AR), indicated Resident 1 was admitted on [DATE], with diagnoses that included Parkinson's Disease without dyskinesia, without mention of fluctuations. Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 11/08/2025, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure for one out of four residents (Resident 1), that Resident 1 was in a room with Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities), EBP was not followed during nursing care. This failure had the potential to spread infection when prevention was not consistently practiced.Findings:During a review of the facility's admission Record (AR), it indicated that Resident 2 was admitted on [DATE], with multiple diagnoses that included Encounter for attention to gastrostomy(a surgical opening into the stomach for a feeding tube to deliver nutrition, hydration, or medication directly). Resident 2's Minimum Data Set (MDS - resident assessment tool) dated 12/25/2025 indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. DS stated he did not work full time and works at least 20 hours a week for the facility. DS further stated he also worked at the sister facility next door for 20 hours a week. RD stated she works part time at the facility, between 8-16 hours a week. During an interview on 3/19/24 at 12:30 p.m., with the Administrator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. Three kitchen air vents and one fly trap by the outside door with excessive blackish dust. 6. Floor drains and air gap by the ice machine and walk-in refrigerator had brownish black discoloration. 7. Dietary staff picked up trash from the kitchen floor and proceeded to distribute water from beverage cart without…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe medication storage when the following medications were found in medication cart one: 1. Resident 22 did not have an accurate medication card label for Colchicine that matched the order the physician had prescribed. (Colchicine is a medication used to prevent or treat gout attacks. Gout is a disease that causes severe pain, swelling, redness and tenderness in joints). 2. Three and one-half loose pills were not in a labeled container. This failure had the potential for medication error and contamination. Findings: 1. During a review of the admission record, dated 3/19/24, indicated Resident 22 was admitted on [DATE], with the diagnosis of gout. During a medication administration observation on 3/19/24, at 8:21 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 gave Resident 22 one tablet of Colchicine 0.6 milligrams (mg) from Resident 22's medication card with a direction label that indicated to give Colchicine one tablet two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to dispose of garbage and contain refuse properly when the dumpster was not closed. This failure had the potential of harborage and feeding of pests. Findings: During an observation on 3/19/24 at 8:39 a.m., with Dietary Services Supervisor (DS), one dumpster located by the side of the facility was full of trash bags and not closed or covered. There was no staff presence around the dumpster area. During an interview on 3/19/18 at 8:39 a.m., DS stated the dumpster was supposed to be closed. During an interview on 3/19/24 at 09:01 a.m., with Maintenance Director (MS) and Administrator (Admin), MS stated the dumpster was to be closed when not in-use. During a review of the facility's policy and procedure (P&P), titled, Medical Waste, Handling of, revised September 2010, indicated outside compactor/dumpster must be locked when not in use and at night.

Based on interview and record review, the facility failed to follow a written hospice (end-of-life) agreement that included joint responsibilities to develop and implement plan of care for one sampled resident (Resident 23) was admitted into the hospice program, when Resident 23 and Resident 23's representative (FM 1) were not included or participated in the development and implementation of Resident 23's hospice plan of care (POC). This failure had the potential to result in negative outcomes and lack of communication of a person-centered care needs for residents. Findings: Review of the Significant change in status-Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 2/24/24, indicated; Resident 23's diagnoses included Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language) and senile degeneration of the brain (Dementia). Resident 23's Basic Interview of Mental status (BIMS) score was 01 poor cognition). Resident 23 had a clear speech, usually understood and understood others.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record, the facility's Quality Assessment Performance Improvement (QAPI) committee failed to identify an adverse event (untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof, including near misses) and the root cause resulting in the death of one (Resident 1) of three sampled residents. Resident 1 was a full code (all emergency interventions in the event breathing and or heart stops). Staff failed to provide emergency medical treatment when Resident 1 was found unresponsive because nursing staff mistakenly thought Resident 1 had a Do Not Resuscitate (DNR) order. This failure resulted in the QAPI committee not taking steps to review the circumstances of Resident 1's death and monitor their system for code status verification to correct the issue. Findings: A review of resident 1 ' s Physician Orders for Life Sustaining Treatment form (POLST-directs individual end-of-life preferences during a medical emergency), dated [DATE], was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices when: 1. The walk-in refrigerator had four trays of previously frozen raw meat in the refrigerator for more than three days; the raw meat was not labeled with a use by date. 2. The reach-in refrigerator had undated and unlabeled individually packaged liquids and a bowl of cooked oatmeal. 3. Two dietary personnel did not perform hand hygiene and or glove changes during food handling. 4. The ice machine interior had a pink substance on the ice chute surface, and the exterior surface of the ice bin had a white residue along the bin seams. These failures had the potential to result in food contamination and foodborne illnesses. Findings: 1. During a concurrent kitchen observation and interview with [NAME] 1, on 3/21/22, at 9:43 a.m., the walk-in refrigerator's temperature was 38 degrees Fahrenheit (F). The bottom shelf of the refrigerator had four separate trays of raw meat labeled and dated as follows: pork 3/18/22; beef 3/18/22; chicken 3/19/22; beef 3/19/22.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to monitor and document the fluid intake of one (Resident 19) of one resident that required dialysis (a treatment for kidney failure to remove waste products and excess fluids by external filtration of blood). The failure to monitor Resident 19's fluid intake for 29 of 90 shifts had the potential to result in Resident 19 consuming more fluids than ordered by the physician causing fluid overload with resultant problems of swollen extremities and difficulty breathing. Findings: A review of the document titled, admission Record, dated 3/24/22, indicated Resident 19 was admitted to the facility in February 2022, with a diagnosis of End Stage Renal Disease (ESRD, the stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplant to maintain life.) A review of Resident 19's Minimum Data Set (MDS, an assessment tool used to guide resident care) dated 3/1/22, indicated Resident 19 was on dialysis. A review of Resident 21's, Order Summary Report, dated 3/24/22,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure one (Resident 22) of one resident receiving anticoagulation medication (medication to prevent blood clot formation, commonly known as blood thinner) was free from unnecessary medication when staff did not monitor the side effects of Resident 22's use of apixaban (medication used to thin blood). This failure had the potential to result in Resident 22 developing adverse side effects such as bleeding. Findings: A review of Resident 22's admission Record indicated Resident 22 was admitted to the facility on [DATE], with a diagnosis of atrial fibrillation (an irregular heart rhythm) and tachycardia (heart rate over 100 beats per minute; the normal rate is 60-100 beats per minute). A review of Resident 22's, Order Summary Report, Active Orders as of 3/24/22, indicated a physician order, start date 2/28/22, for Resident 22 to receive one apixaban tablet two times a day for treatment of tachycardia and monitor for bruising. During a concurrent record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a sanitary environment for two of five sampled residents (Resident 14, Resident 16) when staff failed to: 1. perform hand hygiene between glove changes when administering medication to Resident 14, and 2. clean the oxygen mask and tubing for Resident 16. This failure had the potential for infection of Resident 14 and Resident 16. Findings: 1. During a concurrent observation and interview on 3/23/22 at 09:03 a.m., in Resident 14's room, Licensed Vocational Nurse 2 (LVN 2), LVN 2 prepared Resident 14's medication by opening multiple medication bottles and medication packs with gloved hands and placing the medication into separate medicine cups. With the same gloved hands, LVN 2 went to Resident 14's bedside and touched Resident 14's remote control to adjust Resident 14's bed, adjusted Resident 14's blankets, and handed the medicine cups to Resident 14 without changing gloves or performing hand hygiene. A review of the facility's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and facility document review, the facility failed to label and store food under sanitary conditions when: 1. Five containers of strawberries had white fur on them. Three bananas had black and yellow skin. 2. One loaf of open large wheat bread was without a date. 3. Five small white bowls, two medium bowls two scoops with green handles were stacked and placed in the cabinet with water sitting in them. 4. Registered Dietician (RD) came into the kitchen and did not immediately wash her hands and completely cover her hair. These failures had the potential to cause food contamination and food borne illness in residents. Findings: 1. During an observation on and concurrent interview 8/21/19 at 8:05 a.m., in the walk in freezer, in a box there were five containers of strawberries with white fur on them dated 8/16/19. In the dry storage area, there were three bananas with black and yellow skin . The Dietary Manger (DM) stated fruit is kept three to five days. A review of the policy and procedure titled Storing Produce , dated 2018, indicated to check boxes of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.