A list of the most recent deficiencies for Andbe Home, Inc. 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? |
|---|---|---|---|---|
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-10-13 | 2022-11-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-13 | 2022-11-21 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-10-13 | 2022-11-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-13 | 2022-11-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-13 | 2022-11-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-13 | 2022-11-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-13 | 2022-11-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-13 | 2022-11-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-13 | 2022-11-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-13 | 2022-11-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-13 | 2022-11-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-13 | 2022-11-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-13 | 2022-11-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-29 | 2022-10-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-29 | 2022-10-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-29 | 2022-10-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-14 | 2022-07-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-06-14 | 2022-07-08 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-08-10 | 2021-09-13 | 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 | 2021-08-10 | 2021-09-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-10 | 2021-09-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-10 | 2021-09-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-10 | 2021-09-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-10 | 2021-09-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-10 | 2021-09-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-10 | 2021-09-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-29 | 2021-07-16 | 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 | 2021-06-29 | 2021-07-16 | 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 | 2021-06-29 | 2021-07-16 | 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 | 2021-06-29 | 2021-07-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-29 | 2021-07-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-29 | 2021-07-16 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-12-11 | 2020-01-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-12-11 | 2020-01-16 | 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 | 2019-12-11 | 2020-01-16 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-12-11 | 2020-01-16 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-12-11 | 2020-01-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-11 | 2020-01-16 | 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 | 2019-12-11 | 2020-01-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-11 | 2020-01-16 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-09-04 | 2019-10-03 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-09-04 | 2019-10-03 | N |
| Develop a communication plan. | Fire Safety | 2019-09-04 | 2019-10-03 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-09-04 | 2019-10-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-04 | 2019-10-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-04 | 2019-10-03 | 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 | 2019-09-04 | 2019-10-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-04 | 2019-10-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-04 | 2019-10-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-04 | 2019-10-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-04 | 2019-10-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-04 | 2019-10-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-04 | 2019-10-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-04 | 2019-10-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-04 | 2019-10-03 | N |
