Deficiency Records for Brian Center Nursing Care - St Andrews
Updated as of March 01, 2024
A list of the most recent deficiencies for Brian Center Nursing Care - St Andrews. 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 pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-12 | 2023-08-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-28 | 2023-05-26 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-09 | 2022-06-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-09 | 2022-06-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-21 | 2022-06-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-21 | 2022-06-17 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-04-21 | 2022-06-17 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-04-21 | 2022-04-29 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-21 | 2022-04-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-21 | 2022-04-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-18 | 2022-03-23 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-10-28 | 2022-01-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-28 | 2022-01-11 | 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 | 2021-10-28 | 2022-01-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-10-28 | 2021-12-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-10-28 | 2021-12-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-28 | 2021-12-17 | N |
| Respond appropriately to all alleged violations. | Health | 2021-10-28 | 2021-12-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-10-28 | 2021-12-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-28 | 2021-12-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-28 | 2021-12-17 | 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 | 2021-10-28 | 2021-12-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-10-28 | 2021-12-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-10-28 | 2021-12-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-28 | 2021-12-17 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-10-28 | 2021-12-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-25 | 2021-12-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-28 | 2021-10-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-30 | 2021-07-29 | Y |
| 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 | 2021-06-30 | 2021-07-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-28 | 2021-06-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-18 | 2021-06-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-05-18 | 2021-06-04 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-05-18 | 2021-06-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-30 | 2021-04-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-24 | 2020-03-31 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-10-05 | 2018-11-11 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2018-10-05 | 2018-11-11 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2018-10-05 | 2018-11-11 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-10-05 | 2018-11-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-10-05 | 2018-11-11 | 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 | 2018-10-05 | 2018-11-11 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-10-05 | 2018-11-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-10-05 | 2018-11-11 | N |
| Respond appropriately to all alleged violations. | Health | 2018-10-05 | 2018-11-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-05 | 2018-11-11 | 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 | 2018-10-05 | 2018-11-11 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-10-05 | 2018-11-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-05 | 2018-11-11 | 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 | 2018-10-05 | 2018-11-11 | N |
| Provide activities to meet all resident's needs. | Health | 2018-10-05 | 2018-11-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-10-05 | 2018-11-11 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-10-05 | 2018-11-11 | 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 | 2018-10-05 | 2018-11-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-05 | 2018-11-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-05 | 2018-11-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-05 | 2018-11-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-10-05 | 2018-11-11 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-10-04 | 2018-10-06 | N |
