A list of the most recent deficiencies for St Andrew's at Francis Place. 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-12 | 2023-11-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-12 | 2023-11-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-12 | 2023-11-10 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-12 | 2023-11-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-12 | 2023-11-10 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-10-12 | 2023-11-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-10-12 | 2023-11-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-10-12 | 2023-11-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-12 | 2023-11-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-12 | 2023-11-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-12 | 2023-11-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-16 | 2023-09-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-16 | 2023-09-14 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-16 | 2023-09-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-26 | 2023-08-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-13 | 2021-08-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-13 | 2021-08-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-10-23 | 2020-12-01 | 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 | 2020-10-23 | 2020-12-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-23 | 2020-12-01 | 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 | 2020-10-23 | 2020-12-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-10-23 | 2020-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-10-23 | 2020-12-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-10-23 | 2020-12-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-10-23 | 2020-12-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-19 | 2019-05-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-04-19 | 2019-05-22 | N |
| Respond appropriately to all alleged violations. | Health | 2019-04-19 | 2019-05-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-19 | 2019-05-22 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-04-19 | 2019-05-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-19 | 2019-05-22 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-04-19 | 2019-05-22 | 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 | 2019-04-19 | 2019-05-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-04-19 | 2019-05-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-19 | 2019-05-22 | N |
