A list of the most recent deficiencies for St Andrews Healthcare. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-11 | 2023-10-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-09 | 2023-01-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-09 | 2023-01-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-09 | 2023-01-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-09 | 2023-01-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-09 | 2023-01-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-09 | 2023-01-08 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-12-09 | 2023-01-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-09 | 2023-01-08 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-12-09 | 2023-01-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-09 | 2023-01-08 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2022-12-09 | 2023-01-08 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2022-12-09 | 2023-01-08 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-12-07 | 2023-01-08 | 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 | 2022-12-07 | 2023-01-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-07 | 2023-01-08 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-12-07 | 2023-01-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-07 | 2023-01-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-12-09 | 2022-12-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-30 | 2022-01-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-30 | 2022-01-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-17 | 2021-12-17 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-09-03 | 2021-10-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-03 | 2021-10-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-03 | 2021-10-03 | N |
| Dispose of garbage and refuse properly. | Health | 2021-09-03 | 2021-10-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-03 | 2021-10-03 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-09-03 | 2021-10-03 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-09-03 | 2021-10-03 | 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 | 2021-09-01 | 2021-10-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-09-01 | 2021-10-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-01 | 2021-10-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-09-01 | 2021-10-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-01 | 2021-10-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-02 | 2021-04-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-28 | 2020-03-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-28 | 2020-03-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-28 | 2020-03-31 | 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 | 2020-02-28 | 2020-03-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-28 | 2020-03-31 | N |
| 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 | 2020-02-28 | 2020-03-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-28 | 2020-03-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-28 | 2020-03-31 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2020-02-28 | 2020-03-31 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2020-02-28 | 2020-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-28 | 2020-03-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-25 | 2020-03-31 | 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 | 2020-02-25 | 2020-03-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-25 | 2020-03-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-28 | 2020-02-28 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-02-28 | 2020-02-28 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-02-28 | 2020-02-28 | N |
