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Deficiency Records for Gregory Wing of St Andrews Village
A list of the most recent deficiencies for Gregory Wing of St Andrews Village. 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 Gregory Wing of St Andrews Village. 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 | 2024-05-15 | 2024-08-01 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-15 | 2024-08-01 | Y |
Address subsistence needs for staff and patients. | Fire Safety | 2024-05-13 | 2024-06-28 | N |
Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-05-13 | 2024-06-28 | N |
List the names and contact information of those in the facility. | Fire Safety | 2024-05-13 | 2024-06-28 | N |
Establish emergency prep training and testing. | Fire Safety | 2024-05-13 | 2024-06-28 | 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 | 2024-05-13 | 2024-06-28 | N |
Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-05-13 | 2024-06-28 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-13 | 2024-06-28 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-13 | 2024-06-28 | 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 | 2024-05-15 | 2024-06-21 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-05-15 | 2024-06-21 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-15 | 2024-06-21 | 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 | 2024-05-15 | 2024-06-21 | N |
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-05-15 | 2024-06-21 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-15 | 2024-06-21 | 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 | 2024-05-15 | 2024-06-21 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-15 | 2024-06-21 | N |
Dispose of garbage and refuse properly. | Health | 2024-05-15 | 2024-06-21 | N |
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-05-15 | 2024-06-21 | N |
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2024-05-15 | 2024-06-21 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-15 | 2024-06-21 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-04 | 2022-06-03 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-04 | 2022-06-03 | N |
Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-05-04 | 2022-06-03 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-04 | 2022-06-03 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2022-05-03 | 2022-05-19 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-03 | 2022-05-19 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-03 | 2022-05-19 | N |
Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-05-03 | 2022-05-19 | N |
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-10-16 | 2021-01-06 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-10-16 | 2021-01-06 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-16 | 2021-01-06 | 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 | 2020-10-14 | 2020-12-18 | N |
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2020-10-14 | 2020-11-16 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-10-14 | 2020-11-16 | N |
Construct fire resistant interior walls. | Fire Safety | 2020-10-14 | 2020-11-16 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-10-14 | 2020-11-16 | N |
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2020-10-14 | 2020-11-16 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-10-14 | 2020-11-16 | N |
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