Deficiency Records for St. Andrew Post-Acute Rehabilitation Center
Updated as of March 01, 2024
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 |
