A list of the most recent deficiencies for 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-09 | 2024-01-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-16 | 2023-08-30 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-07-13 | 2023-07-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-02 | 2023-01-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-04 | 2022-04-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-04 | 2022-04-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-04 | 2022-04-04 | 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 | 2022-03-04 | 2022-04-04 | 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 | 2022-03-04 | 2022-04-04 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-03-04 | 2022-04-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-04 | 2022-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-04 | 2022-04-04 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-03-04 | 2022-04-04 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-03-04 | 2022-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-23 | 2022-03-29 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-03-10 | 2022-03-29 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-10 | 2022-03-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-10 | 2022-03-29 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-02-23 | 2022-03-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-21 | 2021-10-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-21 | 2021-10-28 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-02 | 2019-06-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-02 | 2019-06-14 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-05-02 | 2019-06-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-05-02 | 2019-06-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-02 | 2019-06-14 | 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 | 2019-05-02 | 2019-06-14 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2019-05-02 | 2019-06-14 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-05-02 | 2019-06-14 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-05-02 | 2019-06-14 | 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 | 2019-05-02 | 2019-06-14 | 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 | 2019-05-02 | 2019-06-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-02 | 2019-06-14 | 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 | 2019-05-02 | 2019-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-02 | 2019-06-14 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-05-02 | 2019-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-02 | 2019-06-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-05-02 | 2019-06-14 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-05-02 | 2019-06-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-30 | 2019-05-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-05-11 | 2018-05-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-11 | 2018-05-30 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-05-05 | 2018-05-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-05 | 2018-05-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-05-05 | 2018-05-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-05 | 2018-05-29 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-05-05 | 2018-05-29 | N |
