A list of the most recent deficiencies for Stratford Villa Post-Acute. 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 properly located and lighted "Exit" signs. | Fire Safety | 2022-03-29 | 2022-04-15 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-03-29 | 2022-04-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-29 | 2022-04-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-29 | 2022-04-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-24 | 2022-04-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-24 | 2022-04-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-24 | 2022-04-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-24 | 2022-04-11 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-06 | 2021-07-15 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-26 | 2019-10-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-22 | 2019-09-13 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-26 | 2018-10-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-26 | 2018-10-26 | 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 | 2018-09-26 | 2018-10-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-26 | 2018-10-26 | 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 | 2018-09-26 | 2018-10-26 | N |
