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 |