A list of the most recent deficiencies for St Andrew's at New Florence. 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? |
|---|---|---|---|---|
| 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 | 2023-10-16 | 2023-11-20 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2022-10-27 | 2022-12-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-27 | 2022-12-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-10-27 | 2022-12-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-27 | 2022-12-11 | N |
| Post nurse staffing information every day. | Health | 2022-10-27 | 2022-12-11 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-10-27 | 2022-12-11 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-11-10 | 2022-12-03 | Y |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2022-10-27 | 2022-11-30 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-10-27 | 2022-11-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-27 | 2022-11-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-27 | 2022-11-30 | 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 | 2022-10-27 | 2022-11-30 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-10-27 | 2022-11-30 | N |
| 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 | 2022-10-27 | 2022-11-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-27 | 2022-11-30 | 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 | 2022-10-27 | 2022-11-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-27 | 2022-11-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-27 | 2022-11-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-27 | 2022-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-27 | 2022-11-26 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-10-27 | 2022-11-23 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-10-27 | 2022-11-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-27 | 2022-11-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-27 | 2022-11-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-27 | 2022-11-11 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-10-27 | 2022-11-09 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-10-27 | 2022-10-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-21 | 2019-09-20 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2019-08-21 | 2019-09-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-21 | 2019-09-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-08-21 | 2019-09-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-07-12 | 2018-08-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-07-12 | 2018-08-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-12 | 2018-08-24 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-07-12 | 2018-08-24 | 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 | 2018-07-12 | 2018-08-24 | 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 | 2018-07-12 | 2018-08-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-12 | 2018-08-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-07-12 | 2018-08-24 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-07-12 | 2018-08-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-07-12 | 2018-08-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-07-12 | 2018-08-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-07-12 | 2018-08-24 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-07-12 | 2018-08-24 | N |
