Commonwealth Senior Living at Stratford House

Based on observation during a tour of the facility?s safe secure unit and staff interviews, the facility failed to ensure, except during night hours, when 20 or fewer residents are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit who shall be responsible for the care and supervision of the residents and for every additional 10 residents, or portion thereof, at least one more direct care staff member shall be awake and on duty in the unit. EVIDENCE: 1. During on-site inspection on 08/05/2025, while the licensing inspector (LI) was performing a walk-through of the facility?s safe, secure unit, the LI noted that there were only two direct care staff persons present in the unit. 2. An interview with staff person 4 at approximately 8:21AM revealed to the LI that there were 22 residents in the safe, secure unit and that she and staff person 2 were the only two direct care staff persons working in the unit at the time due to the third direct care staff person running late. 3. An interview with staff person 2 at approximately 8:30AM revealed to the LI that she and staff person 4 had been the only two direct care staff persons working in the safe, secure unit since on or around 7:30AM. 4. During an interview with staff person 1, staff person 1 confirmed that there were 21 residents in the facility?s safe, secure unit and there should have been at least three direct-care staff persons working in the special, care unit as the facility?s nighttime hours would have ended by 7:30AM and the need for three direct care staff persons would have started.

Based on observation during a tour of the facility?s safe, secure unit and staff interview, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision. EVIDENCE: 1. At approximately 8:27AM during on-site inspection on 08/05/2025, the door to the spa in the facility?s safe, secure unit was unlocked and unattended. 2. One licensing inspector (LI) observed a clear, plastic box lock box on the bathroom counter in the spa with resident 8?s name that contained two containers of Vaseline, a container of Bag Balm, two containers of deodorant, and two bottles of lotion; however, the box was unlocked. 3. During an interview with staff person 1, staff person 1 confirmed the box should have been locked due to the items inside of the box being harmful to residents in the safe, secure unit unless they are under the supervision of staff.

Based on facility documentation and staff interview, the facility failed to submit a written report of an incident with all required information to the regional licensing office within seven days from the date of the incident. EVIDENCE: 1. The licensing inspector (LI) received an incident report via email from staff person 1 on 11/04/2024 at 9:42PM regarding resident 17. Staff person 1 stated in the incident report that resident 17 was sent to the hospital on 11/02/2024 at 7:45PM for evaluation due to the resident having a worsening condition. During on-site inspection on 08/05/2025, when the LI asked staff person 1 about the incident report, staff person 1 gave the LI a written statement that the resident was admitted to the hospital and did not return back to the facility until 11/07/2024. 2. The LI received an incident report via email from staff person 1 on 01/26/2025 at 3:15PM regarding resident 18. Staff person 1 stated in the incident report that on 01/23/2025 at 5:45PM resident 18 was observed by staff lying on the floor, positioned flat on her back in her apartment in front of the entrance to the bathroom, and was sent to the hospital. During on-site inspection on 08/05/2025, when the LI asked staff person 1 about the incident report, staff person 1 gave the LI a written statement that the resident returned to the facility on 01/26/2025 from the hospital and had a diagnosis of a UTI. 3. The LI received an incident report via email from staff person 1 on 10/31/2024 at 2:35PM regarding resident 19. Staff person 1 stated in the incident report that on 10/30/2024 at 6:00AM, staff observed that the resident?s shirt was soaked with sweat, the resident was hot to the touch, had a fever of 100, was not alert when staff tried to wake him up, and was sent to the hospital. During on-site inspection on 08/05/2025, when the LI asked staff person 1 about the incident report, staff person 1 gave the LI a written statement that the resident was admitted to the hospital with COVID and returned to the facility on 10/31/2024. 4. The LI received an incident report via email from staff person 1 on 07/202025 at 7:21PM regarding resident 14. Staff person 1 stated in the incident report that on 07/18/2025 at 10:38PM, that while doing rounds, staff observed the resident in the floor in his apartment and was sent to the hospital. During on-site inspection on 08/05/2025, when the LI asked staff person 1 about the incident report, staff person 1 gave the LI a written statement that the resident returned to the facility on 07/24/2025 with a diagnosis of ? ground level mechanical fall resulting in rhabdomyolysis ? POA resolved, hypertensive urgency ? POA resolved, acute kidney injury without CKD, and acute urinary retention secondary to BPH/bladder outlet obs requiring indwelling Foley catheter. 5. The LI received an incident report via email from staff person 1 on 03/13/2025 at 10:48PM regarding resident 20. Staff person 1 stated in the incident report that on 03/12

Based on record review and staff interview, the facility failed to ensure that for private pay individuals, the uniform assessment instrument ( UAI

Based on record review and staff interview, the facility failed to ensure that individualized service plans ( ISP

Based on resident record review and staff interview, the facility failed to ensure that a resident?s skilled nursing needs within the facility shall be met by the facility's employment of a licensed nurse or contractual agreement with a licensed nurse, or by a home health agency or by a private duty licensed nurse. EVIDENCE: 1. On 08/08/2025, staff person 1 emailed the licensing inspector (LI) a signed physician?s order that was from Collateral 4, dated 03/20/2025, for resident 3. The document was for wound orders - wound #1 left, anterior lower leg and stated that resident 3 was being discharged from home health care, that the wound cleanings and peri wound skin care - clean wound with normal saline and dressing ? cover with dry gauze, keep wound clean and dry and change dressing(s) every other day. 2. The resident?s March through August 2025 medication administration records ( MAR

Based on resident record review and staff interview, the facility failed to ensure all resident records shall he kept current and retained at the facility. EVIDENCE: 1. During on-site inspection on 08/05/2025, the record for resident 6 contained an outside agency documentation visit sheet, dated 06/04/2025, that Collateral 2 was at the facility providing wound care to the resident?s bi-lateral lower extremities. The licensing inspector (LI) asked staff person 6 for additional notes for the wound care for resident 6 and staff person 6 informed the LI that the resident had been receiving wound care from Collateral 2 prior to 06/04/2025 but they were unable to locate any additional notes in the facility and would have to reach out to Collateral 2 to obtain the notes. 2. During on-site inspection on 08/05/2025, the record for resident 6 contained a signed physician?s order, dated 07/10/2025, for home health for skilled nursing ? wound care 3 times per week to be performed by Collateral 3; however, the record for resident 6 only contained one note, dated 07/14/2025, that Collateral 3 had been in the facility to provide the ordered wound care to the resident. The LI asked staff person 6 for additional notes for the wound care for resident 6, and staff person 6 informed the LI that they were unable to locate any additional notes in the facility and proceeded to get Collateral 3 to fax the wound care notes to the facility during the on-site inspection.

Based on resident record review and staff interview, the facility failed to implement its written plan for medication management in regard to methods to ensure that each resident?s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. EVIDENCE: 1. The record for resident 2 contained a physician?s order, signed on 07/15/2025, for Polytrim Opthal 1mg/10,000 units eye drops ? 1 drop to right eye every 6 hours for 7 days for conjunctivitis. Resident 2?s July 2025 medication administration record ( MAR

Based on resident record review, resident interview, staff interview, and observation, the facility failed to ensure that a resident may be permitted to keep his own medication in an out-of-sight place in his room if the uniform assessment instrument ( UAI

Based on record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 2 contained a physician?s order, signed on 07/15/2025, for Polytrim Opthal 1mg/10,000 units eye drops ? 1 drop to right eye every 6 hours for 7 days for conjunctivitis which would be a total of 28 doses. The July and August 2025 medication administration records ( MAR

Based on resident record review and resident interview, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber were provided according to instructions and documented. EVIDENCE: 1. The record for resident 3 contains a signed physician?s order, dated 05/29/2025, for compression stockings ? put stockings on in the morning and take off at bedtime. The resident?s August 2025 medication administration record contains the initials of staff person 3 on 08/05/2025 for 7:00AM to 3:00PM that the resident had on compression stockings. During an interview with two licensing inspectors (LIs) and resident 3 at approximately 2:45PM during on-site inspection, the LIs asked resident 3 if she was wearing her compression stockings and the resident pulled up her pants legs to right above her ankles to reveal that she was not wearing compression stockings. The resident informed the LIs that a staff person had taken them off before she went to bed the night before; however, no one offered to put them on her this morning. 2. The record for resident 4 contained a physician?s order, signed on 06/17/2025, with parameters for the resident?s METOPROLOL TARTRATE 100 MG TAB ? Take 1 tab by mouth twice daily for hypertension. The order indicates to hold the METOPROLOL for blood pressure less than 100/60. The July 2025 medication administration record ( MAR

Based on audit of medication cart, resident record review, and staff interview, the facility failed to ensure medications ordered for PRN

Based on observation during a tour of the facility, the facility failed to ensure bedrooms shall contain a table or its equivalent accessible to each bed and an operable bed lamp or bedside light accessible to each resident. EVIDENCE: During on-site inspection on 08/05/2025, the rooms for residents 4, 9 and 10 did not contain a table that was accessible to residents 4, 9 and 10 beds or a bed lamp or bedside light that was accessible to residents 4, 9 and 10.

Based on record review and staff interview, the facility failed to ensure that for each resident with an inability to use the signaling device, the facility shall document rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. EVIDENCE: 1. An interview with staff person 7 revealed that residents 11, 12, 13, 14, and 15 are unable to use the signaling device due to cognitive impairments; therefore, each of those residents require at least daily two-hour rounds between 12:00 AM to 11:00 PM. 2. A review of the July and August 2025 two-hour rounding logs revealed incomplete rounds for resident 11 on 07/02/2025 from 08:00 AM through 02:00 PM 3. A review of the July and August 2025 two-hour rounding logs revealed incomplete rounds for resident 12 on: 07/02/2025 from 08:00 AM through 02:00 PM and 11:00 PM; 07/06/2025 from 05:00 PM through 11:00 PM 4. A review of the July and August 2025 two-hour rounding logs revealed incomplete rounds for resident 13 on: 07/25/2025 from 02:00 PM through 11:00 PM; 07/29/2025 from 12:00 AM through 02:00 PM and 04:00 PM through 11:00 PM; 07/30/2025 from 12:00 AM through 11:00 PM; 08/01/2025 from 12:00 AM through 03:00 PM 5. A review of the July and August 2025 two-hour rounding logs revealed incomplete rounds for resident 14 on: 08/01/2025 from 12:00 AM through 03:00 PM 6. A review of the July and August 2025 two-hour rounding logs revealed incomplete rounds for resident 15 on: 07/12/2025 from 03:00 PM through 11:00 PM; 08/03/2025 from 04:00 AM through 06:00 AM and 09:00 AM through 03:00 PM

Based on a walkthrough of the facility, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident with a serious cognitive impairment, these materials or objects shall be inaccessible to the resident except under staff supervision. EVIDENCE: 1. Interview with staff person 1 revealed that the facility currently has residents in the assisted living section that have serious cognitive impairments. 2. At approximately 8:32AM, the door to resident 10?s room was open, and the resident was not in their room and no staff were present in or around the resident?s room. The licensing inspector (LI) observed multiple bottles of alcohol sitting on the counter beside the refrigerator in the kitchenette of the resident?s room. The LI also observed a spray bottle of Febreze lavender light air located on an end table in the resident?s living room.

Based on resident record review and staff interviews, the facility failed to ensure should a resident who meets the criteria for assisted living care fall, the facility must show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls. EVIDENCE: 1. The uniform assessment instrument ( UAI

Based on resident record review, the facility failed to ensure that a comprehensive individualized service plan ( ISP

Based on resident record review and staff interview, the facility failed to ensure individualized service plans ( ISP

Based on resident record review and staff interviews, the facility failed to ensure that resident records contained signed physician orders. EVIDENCE: 1. The October 2024 medication administration record ( MAR

Based on resident record review, the facility failed to ensure that the use of PRN

Based on a walkthrough of the facility, the facility failed to ensue cleaning supplies and other hazardous materials shall be stored in a locked area. EVIDENCE: 1. Interview with staff person 1 revealed that the facility currently has residents in the assisted living section that have serious cognitive impairments. 2. At approximately 8:10AM, the door to the second-floor spa was unlocked and unattended. The licensing inspector (LI) observed a spray can of zep freshen disinfectant spray located on a side table beside the tub in the spa.

Based on facility document review, resident record review, and staff interview, the facility failed to ensure that it implemented its written plan for medication management. EVIDENCE: 1. The facility?s medication management plan provided to the licensing inspector (LI) by staff 1 on 12/15/2023 indicates in section ?Med 10 ? Handling, Ordering, and Refilling Medications? that no resident shall be allowed to take another?s medication, nor shall staff be allowed to give one resident?s medication to another resident. 2. The record for resident 1 contains a physician?s order, dated 10/27/2023, for morphine take the contents of one prefilled syringe (0.25ML=5MG) by mouth or under tongue every three hours as needed for pain or shortness of breath and a physician?s order, dated 10/27/2023, to discontinue current morphine order every three hours and start morphine take the contents of two prefilled syringes (0.5ML =10MG) by mouth or under tongue every two hours as needed for complaints of pain and/or shortness of breath. 3. The record for resident 2 contains a physician?s order, dated 06/19/2023, for morphine take 0.25ML (5MG) by mouth or under tongue every three hours as needed for pain or shortness of breath. 4. The record for resident 1 contains documentation that resident 1 was administered morphine that was prescribed for resident 2 by the following staff persons: staff person 2 on 10/27/2023 at 9:39PM and 11:00PM; staff person 3 on 10/27/2023 at 11:30PM; staff person 4 on 10/28/2023 at 1:50AM, 3:50AM, and 5:50AM; staff person 5 on 10/28/2023 at 7:50AM, 9:50AM, 11:50AM and 1:50PM and staff person 6 on 10/28/2023 at 3:50PM. Interview with staff person 3 on 12/15/2023 confirmed that this was accurate.

Based on observation, the facility failed to ensure that when medications and dietary supplements are administered by the facility, the storage area shall be locked and single-use and dedicated medical supplies and equipment shall be appropriately stored. EVIDENCE: 1. On the morning of inspection, collateral 1 completed a walk-through of the memory care unit. 2. At approximately 9:25AM, collateral 1 observed that there were two residents sitting at tables in the dining room. Collateral 1 also observed that the MED PREP room was adjacent to the dining room and that the MED PREP room door was unlocked. The inside of the MED PREP room contained a shelf with boxes of safety lancets, safety pen needles, safety syringes, and two 64-ounce bottles of Drug Buster Drug Disposal System liquid. The inside of the MED PREP room also contained an unlocked refrigerator which contained five insulin pens, containers of Ensure nutrition shakes, and containers of Boost nutritional shakes. Collateral 1 did not observe any direct care staff within sight of the residents in the dining room or the MED PREP room. 3. A later interview with staff person 7 revealed that the MED PREP room is to always be locked.

Based on resident record review and staff interview, the facility failed to ensure that all residents took part in a semi-annual review of the emergency preparedness and response plan with documentation of signatures and dates of completion. EVIDENCE: Interview with staff person 5 during on-site inspection on 9/12/2023 at approximately 11:11AM, indicated that the facility did not obtain signatures and dates from residents for the review of the facility?s emergency preparedness and response plan. There was no documentation of signatures and dates of residents? completion of this review.

Based on resident record review, the facility failed to obtain some required resident personal and social information. EVIDENCE: 1. The file for resident 2, admitted on 10/25/2022, lacks information regarding the resident?s current behavioral and social functioning, including strengths and problems. The section of the form the facility uses to document this information is marked N/A (not applicable).

Based on resident record review, the facility failed to address an assessed need on the updated individualized service plan ( ISP

Based on documentation review, the facility failed to have an onsite oversight of special diets. EVIDENCE: 1. The most recent dietitian oversight of special diets dated 6/10/2022 stated, in the first paragraph, that it was done virtually.

Based on resident record review and staff interview, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 4 contained a physician?s order, dated 06/02/2022, for Selan Cream apply topically to buttocks for prevention with brief changes and twice daily. During medication cart audit with staff 2 during on-site inspection on 09/14/2022, staff 2 stated to the LI that the aforementioned medication was not available in the facility. The September 2022 medication administration record ( MAR

Based on resident record review and staff interview, the facility failed to ensure medical procedures ordered by a physician or other prescriber were maintained in the resident?s record. EVIDENCE: The record for resident 2 contained a physician?s order, dated 04/03/2022, for the following: ?check blood pressure and pulse twice daily and fax results to (physician) at (fax number) every Tuesday?. During on-site inspection on 09/14/2022, the blood pressure and pulse for 09/13/2022 from 7:00AM to 3:00PM for the resident was not maintained in the resident?s record and also the record did not contain documentation that the resident?s blood pressure and pulse readings had been faxed to the physician on Tuesday 09/13/2022 as required by the physician?s order. Interview with staff 5 confirmed the aforementioned information was accurate.

Based on observation, the facility failed to ensure that cleaning supplies were kept in a locked place. EVIDENCE: 1. The cleaning cart outside room 211 was open and unattended, with disinfectant, furniture polish, and other cleaning agents accessible to residents.

Based on document review and interview, the facility failed to have a semi-annual review of the emergency preparedness and response plan with all residents. The documentation is required to be signed and dated. EVIDENCE: 1. Staff 6 stated that the review of the emergency preparedness and response plan for residents was done at the resident council meeting. The council meeting notes dated 6/22/2022 show that this was attended by eight (8) residents, and the facility has 50 residents. The first names of the residents are typed in, and there are no signatures.