Deficiency Records for The Retreat at The Stratford
Updated as of June 01, 2021
This is not the most recent data for The Retreat at The Stratford. For the most recent information, click here.
A list of the most recent deficiencies for The Retreat at The Stratford. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2020-10-14 | 2020-11-06 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-04-22 | 2019-06-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-04-22 | 2019-06-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-22 | 2019-06-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-04-22 | 2019-06-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-22 | 2019-06-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-04-22 | 2019-06-04 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-04-22 | 2019-06-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-22 | 2019-06-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-14 | 2019-04-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-14 | 2019-04-05 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-03-14 | 2019-04-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-14 | 2019-04-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-03-14 | 2019-04-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-03-14 | 2019-04-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-04-26 | 2018-06-11 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-04-26 | 2018-06-11 | N |
| Develop a communication plan. | Fire Safety | 2018-04-26 | 2018-06-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-04-26 | 2018-06-11 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-04-26 | 2018-06-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-04-26 | 2018-06-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-04-26 | 2018-06-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-04-05 | 2018-04-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-04-05 | 2018-04-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-05 | 2018-04-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-05-31 | 2017-06-15 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2017-05-31 | 2017-06-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-05-31 | 2017-06-15 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-05-02 | 2017-05-19 | N |
