Retreat At The Stratford, The

Based on interview and record review, the facility failed to ensure the physician was notified of daily weight gains as ordered by the physician for 1 of 1 resident reviewed for notification of change. (Resident 3)Findings include:The clinical record for Resident 3 was reviewed on 2/10/26 at 11:11 a.m. The diagnoses included, but were not limited to, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease, mild persistent asthma with acute exacerbation, and shortness of breath.A care plan, dated 10/3/25, indicated Resident 3 was at risk for complications related to chronic kidney disease. An intervention indicated to monitor the weight and notify the physician of a significant weight change.A physician's order, dated 10/8/25, indicated to weigh the resident daily at 6:00 a.m. and to notify the physician if there was a weight gain of 2 pounds or more over night.Resident 3 had a recorded weight gain of 2 pounds or more on the following dates:On 1/4/26, the weight went to 161 pounds from 157 pounds on 1/3/26.On 1/6/26, the weight went to 162 pounds from…

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 the interdisciplinary team (IDT) assessed to determine a resident was safe to self-administer medications for 1 of 1 resident reviewed for self-medication administration. (Resident D) Findings include: During an observation and interview, on 6/2/25 8:46 a.m., Resident D had a clear plastic medication cup, with pills, on her bedside table next to her meal tray. The resident indicated the staff left her medications in her room. She would take the pills. The clinical record for Resident D was reviewed on 6/2/25 at 10:29 a.m. The diagnoses included, but were not limited to, a fracture of the lower end of the left humerus (upper arm bone) and cirrhosis of the liver. An assessment for self-administration of medication completed by the interdisciplinary team (IDT), a physician's order and a comprehensive care plan for the self-administration of medications was not located in the clinical record. During an observation and interview, on 6/2/25 at 8:52 a.m., LPN 1 indicated the resident's medications were on her…

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 residents were free from verbal abuse and intimidation for 2 of 4 residents reviewed for abuse. (Resident B and C) The deficient practice was corrected on 5/25/25, prior to the start of the survey, and therefore was past noncompliance. Findings include: 1. During an interview, on 6/2/25 at 8:56 a.m., Resident B indicated a staff member had been cross and impatient. She was unable to give the staff member's name (CNA 3). Resident B indicated she had slid down in her bed and CNA 3 accused her of doing it on purpose. She indicated she did not like the accusation. 2. During an interview, on 6/2/25 at 9:00 a.m., Resident C indicated CNA 3 had been verbally rude to her and she filed a complaint. Her remote control had fallen between the wall and the bed. The bed needed to be moved to get the remote. CNA 3 threw her hands up and looked at me like I was crazy and said she don't move beds. Resident C indicated she then asked for some milk. CNA 3 went and got the milk, returned, opened the milk, slammed it down,…

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 the physician was notified of the residents' advanced directives and an order was documented in the residents' medical record for 3 of 3 residents reviewed for advanced directives. (Resident 8, 63 and 68) Findings include: 1. The clinical record for Resident 8 was reviewed on 3/4/25 at 9:51 a.m. The diagnoses included, but were not limited to, hypertension, senile degeneration of the brain, and muscle weakness. An Indiana Physicians Orders for Scope of Treatment (POST) form was completed and signed on 11/12/24 and indicated the resident wished to be a Do Not Resuscitate (DNR). Resident 8 was admitted to the facility on [DATE]. A physician's order, dated 3/4/25, indicated the resident was a DNR. The physician's order was not in place until 3.5 months after the resident was admitted to the facility. 2. The clinical record for Resident 63 was reviewed on 3/4/25 at 2:04 p.m. The diagnoses included, but were not limited to, heart failure, stage 3…

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 interview and record review, the facility failed to ensure person-centered comprehensive care plan interventions were developed for a resident who had a significant weight loss for 1 of 1 resident reviewed for nutrition. (Resident 6) Findings include: The clinical record for Resident 6 was reviewed on 3/4/25 at 12:52 p.m. The diagnoses included, but were not limited to, heart failure, vitamin deficiency, dysphagia, and anorexia. A physician's order, dated 5/1/23, indicated the resident was to be weighed monthly. A vitals tab indicated the following: On 1/1/25, the resident weighed 107.12 pounds. On 2/1/25, the resident weighed 101 pounds. On 2/10/25, the resident weighed 96 pounds. Resident 6 had a significant weight loss of 5.7% in 30 days and then continued to lose more weight on 2/10/25. A Registered Dietician (RD) note, dated 2/18/25, indicated the resident triggered for a significant weight loss. The current body weight was 96 pounds and recommended Ensure Plus (nutritional supplement) twice per day to help with weight stability. A current care plan, effective 4/6/23,…

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 assess and document skin issues for 1 of 2 residents reviewed for quality of care. (Resident 5) Findings include: During an observation, on 3/3/25 at 10:15 a.m., Resident 5 was noted to have multiple bruises on both her arms. The clinical record for Resident 5 was reviewed on 3/4/25 at 11:10 a.m. The diagnoses included, but were not limited to, diabetes mellitus, hypertension, hyperlipidemia, and a history of a stroke. A care plan, initiated on 4/17/24, indicated the resident was at risk for skin alterations and to perform and record complete skin assessments. A physician's order, initiated on 4/18/24, indicated to give aspirin (a medication used to prevent platelets from sticking together and causing clots) 81 milligrams once a day. The only documented bruise found in Resident 5's record was an area on the right lateral elbow. No other skin concerns had been found in the record. During an interview, on 3/3/25 at 10:36 a.m., LPN 2 indicated the resident had lots of bruises. During an interview, on 3/7/25 at…

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 narcotic count sheets were signed off by the on-coming and off-going nurses to ensure an accurate reconciliation was completed for 1 of 1 narcotic book reviewed for reconciliation. Findings include: During an observation, on 3/3/25 at 5:27 a.m., with RN 1 in attendance, the narcotic book was found to be missing entries to show the on-coming and off-going nurses had reconciled the narcotic count and signed the narcotic book to indicate the count had been reviewed. During an interview, on 3/3/25 at 5:27 a.m., RN 1 indicated staff were supposed to sign the narcotic count sheets each shift. A facility document, titled Narcotic Count January 2025 Skilled, was provided by the Director of Nursing on 3/3/25 at 5:29 a.m., and indicated the following: On 1/4/25, there were no signatures for the on-coming and off-going day and evening shifts. On 1/5/25, there were no signatures for the on-coming and off-going day and evening shifts. On 1/11/25, there was no signature for the off-going evening shift. On 1/12/25,…

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 medications were stored in their original packaging, failed to label an open vial with a date, and failed to monitor and document medication refrigerator temperatures for 1 of 1 medication cart and 1 of 1 medication refrigerator reviewed for medication storage. Findings include: 1. During an observation of medication storage, on 3/3/25 at 5:21 a.m., with RN 1 in attendance, the following pills were found outside of their packaging and loose in the cart: One round white oval tablet with imprint C-2. Three small round white tablets. Three oval white tables. One medium round white tablet and one rectangular white tablet. During an interview, on 3/3/25 at 5:21 a.m., RN 1 indicated another nurse last cleaned the cart. 2. During an observation of the medication refrigerator, on 3/3/25 at 5:30 a.m., with RN 1 in attendance, a bottle of Aplisol (tuberculosis testing serum) was found opened and without an open date. During the observation the medication refrigerator temperature logs were reviewed. 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.

Based on observation, interview and record review, the facility failed to ensure a recipe was available and followed for puree foods to ensure nutritive value and flavor was conserved for 2 of 2 residents reviewed for a pureed diet. (Resident 1 and 4) Findings include: During a continuous observation, on 3/4/25 at 10:34 a.m., Dietary Manager (DM) 5 was pureeing tuna melt sandwiches for the residents who required a puree diet. As she was pureeing the sandwich, there was no recipe out and she was using an unmeasured amount of cold milk to thin the food out. During an interview, on 3/4/25 at 10:44 a.m., DM 5 indicated they did not have recipes for how to puree food. They did not have recipes for portion sizes or for what thickeners and thinners to use for each meal. They thinned the meal with the appropriate liquids, and they trained staff in orientation about what liquids to use. During an interview, on 3/4/25 at 11:01 a.m., DM 5 indicated she was not sure how someone would know what liquids to use for the puree if someone had to fill in for absent staff members. They trained staff…

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 food was distributed under safe sanitary conditions for 14 of 14 residents who resided in the nursing home area of the facility. Findings include: During the lunch meal service observation on 4/3/24 from 11:54 a.m. to 12:38 p.m., the following concerns were identified: a. At 11:58 a.m., three meal trays were placed in the food service cart. During an interview on 4/3/24 at 11:59 a.m., [NAME] 3 indicated she had not taken the temperatures of the food prior to placing the three trays in the meal service cart. She was aware the temperature of all foods should be taken prior to placing any meal in the food service cart. b. At 12:03 p.m., [NAME] 3 was taking the temperatures of the food items on the steam table. She dropped the wrapper off of the alcohol wipe on the floor. She bent over an picked the wrapper up with her gloved hands. With the same soiled gloved hands, she continued to take temperatures of the food the steam table. c. At 12:19 p.m., [NAME] 3 was serving meals using her gloved hands to serve…

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 interview and record review, the facility failed to ensure ordered wound treatments were completed as ordered for 1 of 4 residents reviewed for wound treatment (Resident B). Findings include: Resident B's closed clinical record was reviewed on 4/02/24 at 12:02 p.m. Discharge diagnoses included, chronic atrial fibrillation, heart failure, and pacemaker placement. The resident had a 12/22/23 care plan need regarding the placement of a cardiac pacemaker. Review of the resident's Clinical Notes indicated the following: 12/22/23- The resident was admitted to the facility following the placement of a pacemaker. 12/28/23-The resident was admitted after a recent pacemaker implantation. The resident had an incision on her left upper chest. No redness was present at the wound site. 1/2/24-The resident returned from a follow-up visit with the cardiologist. The resident had a new order to clean incision daily with soap and water, no lotions, creams or powders to the incision site. Review of the Clinical Notes indicated the entries were identical on four days, and included the same typo…

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 ongoing communication for continuation of care with the dialysis center for 1 of 1 resident reviewed for dialysis services (Resident 6) Findings include: During an interview on 4/02/24 at 1:54 p.m., Resident 6 was sitting in bed in her room watching TV. She indicated she went to dialysis and had a port to her left chest. Resident 6's clinical record was reviewed on 4/2/24 at 3:18 p.m. Current diagnoses included end stage renal disease (ESRD), dependence on dialysis, and congestive heart failure. The resident had a current April 2024 order for dialysis. The resident had a current care plan problem/need regarding a diagnosis of ESRD and receiving hemodialysis. The goal for this problem was Fluid balance will be maintained and resident will have no complications with hemodialysis through the next review. Approaches/interventions included: Interventions: monitor for complications from dialysis such as: hypoglycemia, hypotension, irritation to access site, and muscle cramps and Dialysis is at ( dialysis…

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.