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Deficiency Records for Stratford Villa Post-Acute
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.
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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-26 | 2024-04-25 | N |
| Use approved construction type or materials. | Fire Safety | 2024-03-26 | 2024-04-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-03-26 | 2024-04-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-03-26 | 2024-04-25 | 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 | 2024-03-26 | 2024-04-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-26 | 2024-04-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-26 | 2024-04-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-03-26 | 2024-04-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-26 | 2024-04-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-03-26 | 2024-04-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-26 | 2024-04-25 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-03-26 | 2024-04-25 | 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 | 2024-03-21 | 2024-04-01 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-03-21 | 2024-04-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-21 | 2024-04-01 | N |
| Dispose of garbage and refuse properly. | Health | 2024-03-21 | 2024-04-01 | 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 | 2024-03-21 | 2024-04-01 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-11-07 | 2023-12-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-07 | 2023-12-03 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-07 | 2023-12-03 | Y |
| 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 |
| 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 |
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