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? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2023-04-04 | 2023-07-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-04 | 2023-07-03 | 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 | 2023-04-04 | 2023-06-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-04 | 2023-06-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-04 | 2023-06-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-04 | 2023-06-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-04 | 2023-06-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-04 | 2023-06-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-04 | 2023-06-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-04 | 2023-06-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-04 | 2023-06-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-04 | 2023-06-29 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-04-04 | 2023-06-29 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-04-04 | 2023-06-29 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-03-14 | 2023-04-28 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-03-14 | 2023-04-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-14 | 2023-04-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-14 | 2023-04-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-14 | 2023-04-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-07 | 2022-07-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-07 | 2022-07-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-03-07 | 2022-07-11 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| Develop a communication plan. | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-07 | 2022-05-27 | 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 | 2022-03-07 | 2022-05-27 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-07 | 2022-05-27 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-02-25 | 2022-05-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-25 | 2022-05-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-02-25 | 2022-05-18 | 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 |
