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🔎 Retreat At The Stratford The

Inspection Results


Inspection Overview

Retreat At The Stratford The has been cited for a total of 24 deficiencies since we began saving each survey.

In Indiana, the average facility has **42.94 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

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.

Survey Date: 2025-03-07
Correction Date: 2025-04-02
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2025-03-07
Correction Date: 2025-04-02
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2025-03-07
Correction Date: 2025-04-02
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2025-03-07
Correction Date: 2025-04-02
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2025-03-07
Correction Date: 2025-04-02
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2025-03-07
Correction Date: 2025-04-02
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2024-04-05
Correction Date: 2024-05-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2024-04-05
Correction Date: 2024-02-21
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-04-05
Correction Date: 2024-05-15
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2023-03-14
Correction Date: 2023-04-28
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2023-03-14
Correction Date: 2023-04-28
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2023-03-14
Correction Date: 2023-04-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2023-03-14
Correction Date: 2023-04-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-03-14
Correction Date: 2023-04-28
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Assess the resident when there is a significant change in condition

Survey Date: 2022-02-25
Correction Date: 2022-05-18
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-02-25
Correction Date: 2022-05-18
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2022-02-25
Correction Date: 2022-05-18
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2020-10-14
Correction Date: 2020-11-06
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2019-03-14
Correction Date: 2019-04-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2019-03-14
Correction Date: 2019-04-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2019-03-14
Correction Date: 2019-04-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2019-03-14
Correction Date: 2019-04-05
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2019-03-14
Correction Date: 2019-04-05
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2019-03-14
Correction Date: 2019-04-05
Category: Pharmacy Service Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**