Deficiency Records for Stratford Commons Rehab and Health Care Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Stratford Commons Rehab and Health Care Center. 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-03-12 | 2024-04-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-08 | 2024-03-11 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-02-08 | 2024-03-11 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-02-08 | 2024-03-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-08 | 2024-03-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-08 | 2024-03-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-08 | 2024-03-11 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-02-08 | 2024-03-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-08 | 2024-03-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-08 | 2024-03-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-02-08 | 2024-03-11 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-02-08 | 2024-03-11 | 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 | 2024-02-08 | 2024-03-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-08 | 2024-03-11 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-02-08 | 2024-03-11 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-02-08 | 2024-03-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-08 | 2024-03-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-08 | 2024-03-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-27 | 2022-11-15 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-09-20 | 2022-10-10 | 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 | 2022-09-20 | 2022-10-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-20 | 2022-10-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-20 | 2022-10-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-20 | 2022-10-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-09-20 | 2022-10-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-20 | 2022-10-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-09-20 | 2022-10-10 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-09-20 | 2022-10-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-20 | 2022-10-10 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-09-20 | 2022-10-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-09-20 | 2022-10-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-20 | 2022-10-10 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-08-16 | 2022-08-29 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-07-28 | 2022-08-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-28 | 2022-08-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-28 | 2022-08-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-28 | 2022-08-29 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-07-28 | 2022-08-29 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-28 | 2022-08-29 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-07-28 | 2022-08-29 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-28 | 2022-08-29 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-28 | 2022-08-29 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-07-28 | 2022-08-29 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-07-28 | 2022-08-29 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-07-28 | 2022-08-29 | Y |
| 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 | 2022-07-28 | 2022-08-29 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-07-28 | 2022-08-29 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-28 | 2022-08-29 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-07-28 | 2022-08-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-28 | 2022-08-29 | Y |
| Implement a program that monitors antibiotic use. | Health | 2022-07-28 | 2022-08-29 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-07-28 | 2022-08-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-20 | 2022-04-22 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-04-07 | 2021-05-17 | 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 | 2021-04-07 | 2021-05-17 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-04-07 | 2021-05-17 | 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 | 2021-04-07 | 2021-05-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-11 | 2021-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-11 | 2021-04-29 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-03-11 | 2021-04-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-03-11 | 2021-04-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-11 | 2021-04-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-03-11 | 2021-04-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-11 | 2021-04-06 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-03-11 | 2021-04-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-03-11 | 2021-04-06 | 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 | 2021-03-11 | 2021-04-06 | N |
