Gregory Wing of St. Andrews Village

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions for 1 of 2 units([NAME] Wing), an activity office and the Laundry/kitchen areas on 3 of 3 environmental tours.1. On 8/11/25 from 10:00 a.m. to 10:20 a.m., a surveyor and the Facilities Manager toured the laundry room and the [NAME] Wing hallway and observed the following

Inspectors wroteBased on record review, interview, and facility policy, the facility failed to ensure an Interdisciplinary Meeting was held within 7 days of completed Minimum Data Set (MDS)/ Assessment Reference Date (ARD) for 3 of 14 Residents reviewed (Resident's (7, 19 and 35). 1. Review of facility policy Care Plans-Comprehensive-Preliminary dated 3/1998 states . The resident's/patient's comprehensive care plan is developed within seven (7) days of the completion of the resident's/patient's comprehensive assessment (MDS) . Review of Resident [R]7's Quarterly MDS/ARD dated 7/18/25. Review of R7's clinical record revealed the IDT was held 7/16/25 (2 days prior to MDS/ARD) completion. During an interview on 8/12/25 at 11:21 a.m., the Licensed Social Worker (LSW) stated that she is supposed to schedule IDTs within 7 days of the MDS /ARD date. [...]

Inspectors wroteBased on observations, record reviews, interviews and facility policy, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 1 of 2 residents reviewed for respiratory care (Resident [R] 6). Additionally, the facility failed to ensure physician orders were followed for 1 of 2 residents receiving oxygen therapy (R1) and failed to ensure complete and accurate documentation of the assessment and monitoring of the resident's respiratory condition for 2 of 2 residents receiving oxygen therapy (R1, R6). 1. On 8/11/25 at 9:09 a.m. and 11:22 a.m., R1 was observed wearing oxygen (O2) via a nasal cannula (NC) with the concentrator flow rate set at 1.5 liters per minute (L/min). On 8/12/25 at 9:34 a.m. [...]

Inspectors wroteBased on observations, interviews, the facility's Storage - Food and Non Food Items policy, the facility's Sanitation-Warewashing-Mechanical/Manual Cleaning/Sanitizing policy, and the facility's Dish machine Temperature and Cleaning Records, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a grease trap cover, floor drain covers and the walk-in freezer; failed to ensure kitchen staff wore appropriate hair coverings; failed to ensure foods were properly dated, labeled and/or discarded past the manufacturer's best used by date for 1 of 1 kitchen tour.(8/11/25)The facility's Sanitation-Ware washing-Mechanical/Manual Cleaning/Sanitizing policy effective date: 04/20/12 noted: Procedure: d) Check temperatures. Record daily the wear washing machines temperatures of both the wash and the rinse cycles on the dishwasher temperature record form. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure garbage was properly disposed of and contained to prevent the harborage and feeding of pests for 3 of 3 days of survey (8/11/25, 8/12/25 and 8/13/25).1. On 8/11/25 at 8:30 a.m., two surveyors observed one of two dumpsters with the front right lid open exposing trash. There was also trash on the ground around the two dumpsters. Additionally, two surveyors observed a trash storage area, outside the maintenance shop area, that had trash piled in and on 3 large, uncovered trash receptacles. On 8/11/2025 at 9:12 a.m., in an interview with a surveyor, the Administrator confirmed the finding. 2. On 8/11/25 at 8:30 a.m., a surveyor and the Facilities Manager observation of trash storage area outside the maintenance shop area. 1 of 3 large, uncovered trash receptacles had trash in it. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 1 of 11 residents reviewed for baseline care plans (Resident #19 (R19). R19 was admitted in February 2025. Review of R19's clinical record lacked evidence that a baseline care plan, including goals and interventions, was developed and implemented within 48 hours of admission. On 8/12/25 at 4:00 p.m. during an interview, the Nurse Manager reviewed R19's baseline care plan and confirmed it was not developed and implemented until 4 days after admission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's care plan was developed in the area of oxygen use for 1of 2 residents reviewed for respiratory care (Resident [R] 1). On 8/11/2025 at 9:09 a.m. and 8/12/25 at 9:00 a.m., R1 was observed wearing oxygen via a nasal cannula. Review of R1's clinical record indicated he/she has diagnoses to include Chronic Obstructive Pulmonary Disease (COPD) and aspiration pneumonia. Review of R1's Quarterly Minimum Data Set assessment, dated 6/9/25, indicated oxygen therapy while a resident. [...]

Inspectors wroteBased on review of performance evaluations and interviews, the facility failed to complete annual performance evaluations timely, at least once every 12 months, for 2 of 5 Certified Nursing Assistants (CNA's 1 & 2).1. Review of CNA1's 2024 Annual Performance Appraisal initiated by Nurse Manager on 10/10/24 states Impersonation Mode You are currently impersonating another user. To stop impersonating, click on the user menu and select Stop Impersonating. I understand that my electronic signature carries the same legal weight and authority as my written signature. Name [CNA1] date 8/12/25. sign: is blank. This evaluation lacks evidence that it was reviewed/or signed by CNA1. [...]

Inspectors wroteBased on Certified Nurse's Aide (CNA) employee education reviews and interview, the facility failed to monitor and ensure that a CNA attended the required 12 hours of annual in-service education, for 1 of 5 randomly selected CNA's employed greater than 1 year. (CNA1). Certified Nursing Assistant (CNA1) was hired on 4/11/16. CNA1 's yearly Inservice education records from 4/11/24 through 4/11/25 state she received 7.09 hours of Inservice hour education and not the required 12 hours. During a review of CNA1's in-service hours on 8/13/25 at 11:03 a.m., Nurse Manager confirming CNA1 did not receive the required 12 hours of in-service education.

Inspectors wroteBased on interviews, the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment for 37 of 37 beds.

Inspectors wroteBased on observations, interview and the facility's Storage - Food and Non Food Items policy effective date: 04/20/12, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a grease trap base, floor drains, ceiling vents, lights and ceiling tiles; failed to ensure facial hair protection was worn; and failed to ensure foods in the walk-in freezer were dated and/or labeled.

Inspectors wroteBased on observations and interviews, the facility failed to ensure garbage was properly disposed of and contained to prevent the harborage and feeding of pests for 3 of 3 days of survey (5/13/24, 5/14/24 and 5/15/24).

Inspectors wroteBased on facility policy, record reviews and interviews, the facility failed to provide residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 2 of 6 residents reviewed for advanced directives (Resident's #24 and #26).

Inspectors wroteBased on facility policy, record review and interviews, the facility failed to report in a timely manner, an injury of unknown origin with serious injury to the Division of Licensing and Certification (DLC) (State Survey Agency) and to Adult Protective Services (APS) (State Agency) for 1 of 1 residents sampled for injuries/accidents. (#27)

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care for 1 of 3 residents that were reviewed for new admissions. (#189)

Inspectors wroteBased on record reviews, interviews and facility policy, the facility failed to update/implement goals and interventions in the area of antibiotic medication use for 1 of 6 residents reviewed for medications (Resident #15).

Inspectors wroteBased on interview, record review and facility policy, the facility failed to review and revise the care plan by an interdisciplinary team (IDT) that included, to the extent possible, participation of the resident and/or his/her representative after each assessment for 1 of 7 sampled residents (Resident #17).

Inspectors wroteBased on interview and clinical record review, the facility failed to develop a discharge summary which included a recapitulation of the resident's stay for 1 of 1 residents reviewed for discharge (Resident #33).

Inspectors wroteBased on observation and interview, the facility failed to ensure that the resident's environment was free of accident hazards relating to a commode for 1 of 3 days of survey. (5/13/24)

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate documentation for 1 of 3 sampled residents reviewed for Oxygen (#189).

Inspectors wroteBased on record review, interviews and facility policy, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, failed to determine that drug records are in order and that an account of all controlled drugs is maintained, failed to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for 1 of 2 units reviewed for medication storage ([NAME] Wing).

Inspectors wroteBased on record review, interview and facility policy, the facility failed to show evidence of documentation to justify the use of psychotropic medications for 2 of 5 residents reviewed for unnecessary medications (#17 and #28).

Inspectors wroteBased on review of the quarterly Quality Patient Resident Safety Committee meeting attendance sheets and interview, the facility failed to ensure that the Infection Preventionists attended 4 of 4 quarterly meetings.

Inspectors wroteBased on observations and interviews, the facility failed to maintain the dignity of 2 residents (Residents #7 and #133) related to urinary collection bags and locomotion during 2 of 3 days of survey (5/2/22 and 5/3/22).

Inspectors wroteBased on record review, facility policy review, and interview, the facility failed to ensure that neurological assessments were completed as directed by facility policy for 1 of 1 residents who had fallen and sustained a head injury (Resident #21).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that a Medical Provider made required visits, reviewed the total plan of care, and wrote a progress note as often as required for 2 of 13 sampled residents (Resident #7 and #21).

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure that cooked foods were handled in a sanitary manner for 1 of 3 days of survey (5/3/22).