Inspection Reports for
Stratford Commons Rehabilitation & Health Care
KS, 66213
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Inspection Report — Nov 18, 2025
Complaint Investigation CMS
Date: Nov 18, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following the elopement of a newly admitted resident who left the facility unsupervised.
Complaint Details
The complaint investigation was triggered by the elopement of Resident 1 on 10/18/25, who was missing for approximately five and a half hours. The resident was found by law enforcement about one mile from the facility. The facility conducted a thorough search and notified police and the resident's representative. The investigation revealed failures in supervision and door security.
Findings
The facility failed to provide adequate supervision to prevent Resident 1, who had intermittent confusion and exit-seeking behaviors, from leaving the facility unnoticed. The South egress door was found unsecured and did not alarm properly, placing the resident in immediate jeopardy.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent Resident 1 from eloping. The South egress door was unsecured and did not alarm when pushed, allowing the resident to leave unnoticed.
Report Facts
Duration of elopement: 5.5
Temperature: 65
Distance from facility: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Documented observations and notifications related to Resident 1's elopement |
| CNA N | Certified Nurse Aide | Reported inability to locate Resident 1 and participated in search efforts |
| Administrative Staff A | Conducted door audits and coordinated search efforts during Resident 1's elopement | |
| Administrative Nurse D | Oversaw staff response and search efforts related to Resident 1's elopement |
Inspection Report — Nov 17, 2025
Complaint Investigation CMS
Date: Nov 17, 2025
Visit Reason
The inspection was conducted based on complaints and concerns related to resident dignity, honoring advance directives, use of psychotropic medications, pressure ulcer care, fall prevention, dialysis care, medication storage, and infection control practices.
Complaint Details
The investigation was complaint-driven, focusing on issues such as disrespectful staff behavior, failure to honor advanced directives, improper medication use, inadequate wound care, fall prevention lapses, dialysis communication failures, expired medications, and infection control breaches. The complaint was substantiated with findings of deficiencies in all these areas.
Findings
The facility was found deficient in multiple areas including failure to ensure dignified care for a resident, failure to honor a resident's do not resuscitate (DNR) advanced directive, improper use of antipsychotic medication without physician rationale, inadequate pressure ulcer assessment and documentation, failure to implement fall prevention interventions, incomplete dialysis communication, presence of expired medications, and failure to follow infection control practices related to Enhanced Barrier Precautions.
Deficiencies (8)
F 0550: The facility failed to ensure a dignified care environment for Resident 8 when staff spoke to her disrespectfully and failed to address bullying by a Certified Nurse's Aide.
F 0578: The facility failed to follow Resident 59's do not resuscitate (DNR) advanced directives and performed CPR without verifying the resident's wishes.
F 0605: The facility failed to ensure Resident 6 was free from antipsychotic medication use without a proper physician indication or rationale.
F 0686: The facility failed to thoroughly assess and document the characteristics and physician notification of Resident 41's Stage 3 and Stage 4 pressure ulcers.
F 0689: The facility failed to implement Resident 8's fall prevention interventions, including the absence of required 'Call Don't Fall' signs in her room and bathroom.
F 0698: The facility failed to ensure Resident 3 received dialysis care with proper communication and collaboration, missing documentation on dialysis communication forms for multiple dates.
F 0761: The facility failed to remove expired medications from medication carts and storage areas, including expired antacid, Vitamin D3, and Ativan vials.
F 0880: The facility failed to follow infection control practices by not wearing gowns when transferring Resident 23 and administering medications to Resident 13 who were on Enhanced Barrier Precautions.
Report Facts
Sample size: 15
Expired medications: 4
Dates missing dialysis communication: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse's Aide | Named in disrespectful conduct and bullying of Resident 8 |
| Administrative Staff A | Notified and suspended CNA M after complaint about disrespectful behavior | |
| Certified Nurse's Aide N | Certified Nurse's Aide | Provided statements regarding staff expectations for dignity and fall prevention |
| Administrative Nurse A | Administrative Nurse | Provided statements on staff training and fall prevention responsibilities |
| Certified Medication Aide R | Certified Medication Aide | Administered medications to Resident 6 |
| Administrative Nurse D | Administrative Nurse | Verified pharmacist recommendations and dialysis communication failures |
| Licensed Nurse G | Licensed Nurse | Provided statements on staff expectations for advanced directives and infection control |
| Licensed Nurse F | Licensed Nurse | Performed wound care for Resident 41 |
| Licensed Nurse I | Licensed Nurse | Performed wound care for Resident 41 |
| Certified Medication Aide S | Certified Medication Aide | Verified expiration dates on medications |
| Administrative Nurse F | Administrative Nurse | Verified expiration dates on medications |
| Licensed Nurse J | Licensed Nurse | Administered medications to Resident 13 without wearing gown |
| Administrative Nurse E | Administrative Nurse | Verified infection control practices and gown use |
Inspection Report — Feb 8, 2024
Routine CMS
Date: Feb 8, 2024
Visit Reason
Routine inspection of Stratford Commons Rehab & Health Care Center to assess compliance with healthcare regulations including care planning, medication administration, resident safety, infection control, and hospice services.
Findings
The facility failed to ensure accurate and complete care plans, proper medication administration including IV competency and psychotropic medication management, adequate resident safety measures including fall prevention and pressure ulcer care, proper infection control practices, and timely provision of vaccinations and hospice communication. Several residents were at risk due to these deficiencies.
Deficiencies (17)
F 0657: The facility failed to revise care plans to include relevant hospice information for Resident 29 and nonpharmacological attempts prior to administering as-needed psychotropic medication for Resident 10.
F 0661: The facility failed to ensure Resident 24's discharge summary included medication reconciliation and instructions.
F 0676: The facility failed to provide supportive care and communication tools to Resident 32 with aphasia, placing him at risk for decreased quality of life and impaired dignity.
F 0677: The facility failed to provide adequate ADL care including nail trimming for Resident 5 and assistance for Resident 9, risking poor hygiene and impaired health.
F 0684: The facility failed to apply Geri Sleeves as ordered for Resident 23 and failed to follow physician-ordered daily weights for Resident 10 on diuretics.
F 0686: The facility failed to implement care plan interventions consistently for Resident 9 with multiple pressure ulcers, risking delayed healing and new injuries.
F 0688: The facility failed to provide services to prevent reduction of range of motion and contractures for Resident 5.
F 0689: The facility failed to ensure safe transfers for Resident 29 and failed to place a fall mat and lower the bed for Resident 9 as ordered, increasing fall risk.
F 0695: The facility failed to ensure physician indication for oxygen administration and proper sanitary storage of oxygen tubing for Resident 29.
F 0698: The facility failed to obtain Resident 102's weight before hemodialysis treatment, risking dialysis complications.
F 0726: The facility failed to ensure Licensed Nurse staff had competency to administer IV medications, resulting in a medication error for Resident 47.
F 0758: The facility failed to ensure nonpharmacological attempts prior to administering as-needed psychotropic medication for Resident 10 and failed to specify a stop date for as-needed psychotropic medication for Resident 101.
F 0760: The facility failed to prevent a significant medication error when Resident 47 received an incorrect IV antibiotic.
F 0838: The facility failed to conduct a thorough, updated facility-wide assessment to determine necessary resources for competent resident care during day-to-day operations and emergencies.
F 0849: The facility failed to ensure communication and documentation between the facility and hospice provider for Resident 29, including description of hospice services, medications, and equipment.
F 0880: The facility failed to implement infection control standards related to Legionella monitoring and sanitary storage of respiratory equipment.
F 0883: The facility failed to provide Resident 39 with the pneumococcal conjugate vaccine as consented, increasing risk for pneumonia complications.
Report Facts
Residents reviewed: 14
Medication refusal dates: 26
Medication missing weight dates: 10
Documentation missing shifts: 20
Documentation refused shifts: 8
Documentation not applicable shifts: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse F | Administrative Nurse | Named in medication error involving wrong IV antibiotic administration to Resident 47 |
| Licensed Nurse G | Licensed Nurse | Provided statements regarding care plans, medication administration, and hospice services |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding care plans, medication administration, hospice services, and facility policies |
| Certified Nurse Aide N | Certified Nurse Aide | Observed assisting Resident 29 and handling oxygen equipment |
| Administrative Nurse E | Administrative Nurse | Provided statements regarding medication administration and vaccination tracking |
| Licensed Nurse I | Licensed Nurse | Discussed IV medication training and competency |
| Consultant Physical Therapist HH | Consultant Physical Therapist | Provided information on Resident 29's transfer status |
| Maintenance Director U | Maintenance Director | Provided information on facility water system and Legionella risk assessment |
Inspection Report — Jul 28, 2022
Routine CMS
Date: Jul 28, 2022
Visit Reason
Routine inspection of Stratford Commons Rehab & Health Care Center to assess compliance with healthcare regulations including resident care, medication management, infection control, and facility operations.
Findings
The facility failed in multiple areas including failure to provide required Medicare non-coverage notices, inconsistent bathing and personal hygiene care, inadequate diabetic and dialysis monitoring, improper catheter and feeding tube care, insufficient dementia care, inappropriate medication use, poor infection control practices, and ineffective quality assurance processes.
Deficiencies (16)
F582: The facility failed to issue required Medicare Non-Coverage notices to inform residents of their appeal rights and potential financial liability.
F677: The facility failed to provide consistent bathing and personal hygiene assistance to residents requiring help, placing them at risk for skin complications and impaired dignity.
F684: The facility failed to ensure physician ordered daily weights and diabetic monitoring were completed, placing residents at risk for complications related to congestive heart failure and diabetes.
F690: The facility failed to provide a toileting program and failed to maintain sanitary catheter care, increasing risk for urinary tract infections and incontinence.
F693: The facility failed to provide physician ordered abdominal binder use, failed to maintain sanitary enteral feeding equipment, and failed to document feeding residuals, increasing risk of feeding tube complications.
F698: The facility failed to obtain dialysis communication sheets, measure weights as ordered, and obtain weekly labs for dialysis residents, placing them at risk for dialysis-related complications.
F744: The facility failed to provide person-centered dementia care, resulting in decreased quality of life and impaired well-being for residents with dementia.
F756: The facility failed to ensure the consultant pharmacist identified and reported inappropriate antipsychotic medication diagnoses and missed insulin administration.
F757: The facility failed to administer physician ordered insulin and perform blood glucose monitoring as ordered, and failed to document physician notification of abnormal blood sugars.
F758: The facility failed to ensure residents with dementia had appropriate diagnoses for antipsychotic medication use, risking unnecessary medication and side effects.
F812: The facility failed to maintain sanitary food preparation, equipment cleaning, and food storage practices, increasing risk for foodborne illness.
F867: The facility failed to maintain an effective quality assurance program to identify and correct quality deficiencies, risking ineffective care.
F880: The facility failed to ensure proper hand hygiene during peri-care, failed to disinfect shared equipment, and failed to store clean linens in a sanitary manner, increasing infection risk.
F881: The facility failed to implement an effective antibiotic stewardship program, lacking tracking and trending of antibiotic use and resistant organisms.
F883: The facility failed to obtain influenza and pneumococcal vaccination consents, declinations, or administration records for several residents, increasing risk for vaccine-preventable diseases.
F807: The facility failed to provide requested thickened liquids to a resident during meal service, placing the resident at risk for dehydration and discomfort.
Report Facts
Missed IV fluid administrations: 14
Missed insulin administrations: 8
Missed blood sugar checks and insulin administrations: 5
Missed dialysis communication sheets: 8
Missed dialysis weights: 9
Missed dialysis labs: 3
Missed dialysis communication sheets: 3
Missed dialysis weights: 4
Missed infection control logs: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Mentioned in relation to bathing refusals, catheter care, Hoyer lift use, and feeding assistance |
| LN G | Licensed Nurse | Mentioned in relation to bathing supervision, diabetic care, dialysis communication, infection control, and medication administration |
| Administrative Nurse D | Administrative Nurse | Mentioned in relation to bathing oversight, dialysis communication, infection control, medication review, and quality assurance |
| CNA N | Certified Nurse Aide | Mentioned in relation to dementia care and transfers |
| CP GG | Consultant Pharmacist | Mentioned in relation to medication regimen review and reporting irregularities |
| Administrative Staff A | Administrative Staff | Mentioned in relation to quality assurance program |
| Dietary Staff BB | Dietary Staff | Mentioned in relation to food service and hydration |
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