A list of the most recent deficiencies for The Springs at St Andrews Village. 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? |
|---|---|---|---|---|
| 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. | Health | 2022-12-15 | 2023-03-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-15 | 2023-03-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-05 | 2023-02-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-05 | 2023-01-25 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-01-05 | 2023-01-25 | 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 | 2023-01-05 | 2023-01-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-05 | 2023-01-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-05 | 2023-01-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-05 | 2023-01-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-05 | 2023-01-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-15 | 2023-01-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-15 | 2023-01-09 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-12-15 | 2023-01-09 | 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 | 2022-12-15 | 2023-01-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-18 | 2022-08-26 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-08-18 | 2022-08-22 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-08-18 | 2022-08-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-18 | 2022-08-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-18 | 2022-08-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-23 | 2022-03-24 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-16 | 2022-01-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-16 | 2021-11-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-09-16 | 2021-11-05 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-11 | 2021-10-19 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-10-11 | 2021-10-19 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-11 | 2021-10-19 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-16 | 2021-10-05 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-09-16 | 2021-10-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-16 | 2021-10-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-09-16 | 2021-10-01 | 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 | 2021-09-16 | 2021-10-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-16 | 2021-10-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-24 | 2021-09-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-24 | 2021-09-17 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-08-24 | 2021-09-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-24 | 2021-09-17 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-09-16 | 2021-09-16 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-08-24 | 2021-09-15 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-08 | 2019-11-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-08 | 2019-11-01 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-09-12 | 2019-11-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-12 | 2019-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-12 | 2019-10-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-08 | 2019-10-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-12 | 2019-10-12 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-09-12 | 2019-10-12 | 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 | 2019-09-12 | 2019-10-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-12 | 2019-10-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-08 | 2019-10-09 | N |
