The Springs at St. Andrews Village

Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:No written record of the conti.. Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 101 7.9.3 and 19.2.9.1.1.Emergency lighting no annual .. Based on observation and staff interview during record review, it was determined that the facility failed to maintain Fire/smoke doors in accordance with Life Safety Code NFPA 101 8.3.3.1 and 19.2.2.2.10.2.1.Mechanical room next to.. Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. Nutrition room fire caulk missing around a conduit NFP.. Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.31.119 door door doesn ' t latch2.219 .. Based on observation and staff interview it was determined that the facility failed to maintain a fire safe environment within the facility Life Safety Code, Section 19.7.81.Portable space heater used in Rooms (front reception area, HR o.. Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1.East and West stairwell 1st and 2.. Based on observation and staff interview, it was determined that the facility failed to maintain wiring in accordance with NFPA 101 and NFPA 70.1.Exposed wires hanging from the ceiling in the rehab room.2.Nutrition room 2 east and .. Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Facility missing fire drill in third and fourth quarter of the year. NFPA 101, 19.7... INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This .. Through observation and staff interview of the fire alarm system during the survey, the facility failed to install and maintain the Interior wall and ceiling finishes in accordance with NFPA 101 Life Safety Code (2012 Edition), section 1.. Through observation during the survey, it was determined that the facility failed to meet the Combustible Decorations requirements in accordance with NFPA 101, 19.7.5.6. This was evidenced by: 1) Facility has decorations outside pati.. Through observation during the survey, it was determined that the facility failed to meet the exit signage requirements in accordance with NFPA 101, 19.2.10.1. This was evidenced by:1.Exit Lights no annual 30 seconds insp.. Through observation during the survey, it was determined that the facility failed to meet the health care facilities code requirements in accordance with NFPA 99 and NEC 70. This was evidenced by: 1.Fridge into power strip b..

A recertification survey was conducted from 3/25/24 to 3/27/24. Five deficiencies were cited. An Emergency Preparedness survey was conducted from 3/25/24 to 3/27/24. No deficiencies were cited. Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly in two of three medication storage rooms and one of three medication carts.Specifically the facility failed to:-Ensure expired medications were not stored with current medications in the medication storage rooms;-Ensure medications were stored at correct temperatures in medication storage refrigerators;-Ensure medications were not stored in a dormitory style refrigerator/freezer combination; and, -Ensure used medication vials were not stored in t.. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for one of two units.Specifically, the facility failed to:-Ensure resident rooms and bathrooms were cleaned in a sanitary manner;-Ensure surface disinfectants were used for the appropriate dwell time (amount of time surface must remain visibly wet);-Ensure appropriate hand hygiene was performed by housekeeping staff; and,-Ensure high t.. Based on record review and interview, the facility failed to conduct yearly certified nurse aide (CNA) performance reviews and provide training based on the outcome of the reviews for three out of five CNAs reviewed for annual reviews and training. Specifically, failed to provide performance reviews annually and training based on the outcome of the individual reviews for CNA #1, CNA #2 and CNA #3. Findings include:I. Facility policy and procedureThe Performance Evaluations policy, revised September 2020, was provided by the executive director (ED) on 3/27/24 at .. Based on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received the required 12 hours of annual in-service training to ensure continued competence.Specifically, the facility failed to ensure 23 of 24 CNAs received 12 hours of annual training.Findings include:I. Facility policy and procedureThe In-Service Training policy, revised August 2022, was provided by the executive director (ED) on 3/27/24 at 12:25 p.m. It documented in pertinent part, "The primary objective of the in-service training was to ensure that staff were able to interact in a m.. Based on record review and interviews, the facility failed to ensure one (#25) of five residents out of 19 sample residents received treatment and care in accordance with professional standards of practice.Specifically, the facility failed to administer medications in a timely manner per the physician orders for Resident #25.Findings include:I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.sevier, St. Louis Missouri, pp. 606-607. "Take appropriate actions to ensure the patient receives medication as prescribed an..