Retreat at the Stratford, The

In the surveyor’s words

From the most serious findings on record at Retreat at the Stratford, The, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Apr 5, 2024

  Based on observation, interview, and record review, the facility failed to ensure food was distributed under safe sanitary conditions for 14 of 14 residents who resided in the nursing home area of the facility. Findings include: During the lunch meal service observation on 4/3/24 from 11:54 a.m. to 12:38 p.m., the following concerns were identified: a. At 11:58 a.m., three meal trays were placed in the food service cart. During an interview on 4/3/24 at 11:59 a.m., Cook 3 indicated she had not taken the temperatures of the food prior to placing the three trays in the meal service cart. She was aware the temperature of all foods should be taken prior to placing any meal in the food service cart. b. At 12:03 p.m., Cook 3 was taking the temperatures of the food items on the steam table. […]

• No harm, potential for more than minimal, widespreadF812Mar 14, 2023

  Based on observation, interview and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in the potential for food borne illness for all residents who consume food from the kitchen. Findings include: 1. During an initial kitchen tour, on 03/09/23 at 9:48 a.m., with the Director of Dining Services (DDS) the following were observed: a) a large bin of yellow cornmeal like substance was noted with no open date on the bin. b) a large bin of bread crumb like substance was noted with no open date on the bin. c) a large bin of white sugar like substance was noted with no open date on bin. During an interview, on 03/09/23 at 9:48 a.m., the DDS indicated he did not know when the food was placed in the large bins without an open date on the bins. 2. […]

• No harm, potential for more than minimal, patternF656Feb 25, 2022

  Based on interview, record review and observation, the facility failed to develop a comprehensive and person centered plan of care which included measurable objectives and time frames to meet the resident's nursing, medical and psychological needs for 5 of 8 residents reviewed for care plans. (Residents 7, 63, 4, 1 and 5). Findings include: 1. The record for Resident 7 was reviewed on 02/23/2022 at 2:32 p.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During observations, in the dining room, on 02/21/2022 at 12:41 p.m., and 02/24/2022 at 12:31 p.m., Resident 7 was seated in a wheelchair and fed herself without difficulty. The resident was observed to be in bed, with eyes closed, on 02/22/2022 at 2:21 p.m., 02/23/2022 at 10:32 a.m., and 02/24/2022 at 3:42 p.m. […]

• No harm, potential for more than minimal, isolatedF580Feb 12, 2026

  Based on interview and record review, the facility failed to ensure the physician was notified of daily weight gains as ordered by the physician for 1 of 1 resident reviewed for notification of change. (Resident 3)Findings include:The clinical record for Resident 3 was reviewed on 2/10/26 at 11:11 a.m. The diagnoses included, but were not limited to, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease, mild persistent asthma with acute exacerbation, and shortness of breath.A care plan, dated 10/3/25, indicated Resident 3 was at risk for complications related to chronic kidney disease. […]

• No harm, potential for more than minimal, isolatedF554Jun 2, 2025

  Based on observation, interview and record review, the facility failed to ensure the interdisciplinary team (IDT) assessed to determine a resident was safe to self-administer medications for 1 of 1 resident reviewed for self-medication administration. (Resident D) Findings include: During an observation and interview, on 6/2/25 8:46 a.m., Resident D had a clear plastic medication cup, with pills, on her bedside table next to her meal tray. The resident indicated the staff left her medications in her room. She would take the pills. The clinical record for Resident D was reviewed on 6/2/25 at 10:29 a.m. The diagnoses included, but were not limited to, a fracture of the lower end of the left humerus (upper arm bone) and cirrhosis of the liver. […]