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Deficiency Records for St Andrew's at Francis Place

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.

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
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

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