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Deficiency Records for St. Andrew Post-Acute Rehabilitation Center

A list of the most recent deficiencies for St. Andrew Post-Acute Rehabilitation Center. 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?
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	Health	2022-09-09	2022-10-09	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	2022-09-09	2022-10-09	N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.	Health	2022-09-09	2022-10-09	N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	Health	2022-09-09	2022-10-09	N
Provide appropriate treatment and care according to orders, resident?s preferences and goals.	Health	2022-09-09	2022-10-09	N
Provide safe and appropriate respiratory care for a resident when needed.	Health	2022-09-09	2022-10-09	N
Provide safe, appropriate dialysis care/services for a resident who requires such services.	Health	2022-09-09	2022-10-09	N
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.	Health	2022-09-09	2022-10-09	N
Ensure medication error rates are not 5 percent or greater.	Health	2022-09-09	2022-10-09	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	2022-09-09	2022-10-09	N
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.	Health	2022-09-09	2022-10-09	N
Install emergency lighting that can last at least 1 1/2 hours.	Fire Safety	2022-09-07	2022-10-09	N
Provide properly protected cooking facilities.	Fire Safety	2022-09-07	2022-10-09	N
Have approved installation, maintenance and testing program for fire alarm systems.	Fire Safety	2022-09-07	2022-10-09	N
Inspect, test, and maintain automatic sprinkler systems.	Fire Safety	2022-09-07	2022-10-09	N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Fire Safety	2022-09-07	2022-10-09	N
To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Fire Safety	2022-09-07	2022-10-09	N
Have generator or other power source capable of supplying service within 10 seconds.	Fire Safety	2022-09-07	2022-10-09	N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	Health	2021-09-29	2021-11-10	Y
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	Health	2021-09-29	2021-11-10	Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	Health	2021-05-27	2021-06-27	Y
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	Health	2021-05-27	2021-06-27	Y
Provide properly protected cooking facilities.	Fire Safety	2021-05-25	2021-06-27	N
Have properly installed electrical wiring and gas equipment.	Fire Safety	2021-05-25	2021-06-27	N
Have generator or other power source capable of supplying service within 10 seconds.	Fire Safety	2021-05-25	2021-06-27	N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	Health	2019-10-31	2019-12-01	N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	Health	2019-10-31	2019-12-01	N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	Health	2019-10-31	2019-12-01	N
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	2019-10-31	2019-12-01	N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	Health	2019-10-31	2019-12-01	N
Dispose of garbage and refuse properly.	Health	2019-10-31	2019-12-01	N
Provide and implement an infection prevention and control program.	Health	2019-10-31	2019-12-01	N
Keep aisles, corridors, and exits free of obstruction in case of emergency.	Fire Safety	2019-10-31	2019-12-01	N
Install emergency lighting that can last at least 1 1/2 hours.	Fire Safety	2019-10-31	2019-12-01	N
Have approved installation, maintenance and testing program for fire alarm systems.	Fire Safety	2019-10-31	2019-12-01	N
Inspect, test, and maintain automatic sprinkler systems.	Fire Safety	2019-10-31	2019-12-01	N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Fire Safety	2019-10-31	2019-12-01	N

Deficiency Records for St. Andrew Post-Acute Rehabilitation Center

Updated as of May 01, 2024

Deficiency Records for St. Andrew Post-Acute Rehabilitation Center

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