St. Andrews Operator, LLC

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure foods that are stored in the freezer, refrigerator and dry food storage were appropriately sealed, labeled, dated with a use by date, and/or discarded after the manufacturer's expiration date in 1 of 1 kitchen.

Inspectors wroteBased on observation, interview, document review, and facility policy review, the facility's quality assurance and performance improvement (QAPI) committee failed to implement effective corrective actions to ensure previously identified deficient practices were corrected and sustained. This deficient practice had the potential to affect all 91 residents who resided in the facility. Cross Reference: F693, F761, and F812.

Inspectors wroteF880Based on review of facility policy, observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to produce documentation of a surveillance plan, based on a facility assessment, for tracking, and/monitoring infections, communicable diseases and outbreaks among residents and staff for the entire year 2024 and the months of January 2025 and February 2025.

Inspectors wroteBased on review of the facility policy, observations, record review and interviews, the facility failed to remove expired and discontinued medications from storage and failed to label and date open medications in 3 of 6 medication carts.

Inspectors wroteBased on review of facility policy, record review and interviews, the facility failed to ensure resident assessments accurately reflected the resident's status for pressure ulcers for 1 of 2 residents, Resident (R)10, reviewed for pressure ulcers. Specifically, R10 was readmitted to the facility on [DATE] with a sacral pressure ulcer that was not documented on his skin assessment or Minimum Data Set (MDS).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to timely develop a baseline care plan for 1 (Resident (R)502) of 7 sampled residents.

Inspectors wroteBased on review of facility policy, record review, observations and interviews, the facility failed to ensure a resident with continuous tube feed received the correct ordered amount and rate of tube feed. The facility also failed to label and date a tube feed bag for 1 of 1 resident, Resident (R)9 reviewed for tube feedings. Specifically, R9's tube feed was infusing at 45 milliliters (ml) per hour (hr) instead of the physician's ordered rate of 50 ml per hour. Review of the facility policy titled Enteral Tube Feeding via Continuous Pump last revised on 11/18, states, The purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings. General Guidelines. 3. Check the enteral nutrition label against the order before administration. Check the following information: Resident name, ID and room number; Type of formula; Date and time formula was prepared; [...]

Inspectors wroteBased on review of facility policy, record review, observation, and interview, the facility failed to provide respiratory care in accordance with professional standards. Specifically, the facility failed to ensure one nebulizer machine, one oxygen mask and one medication chamber were clean and/or bagged when not in use for 1 of 2 residents (Resident (R)82), reviewed for respiratory care.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to protect one non-interviewable, cognitively impaired Resident (R2) from a non-consensual sexual encounter with R1. Despite prior documentation of R1's inappropriate and unsafe behaviors toward female residents, the facility did not implement timely or adequate interventions to prevent further incidents. On April 25, 2025 at 5:26 PM, the Administrator and Director of Nursing (DON) were notified that the failure to protect Resident (R)2 from a non-consensual sexual encounter with R1 constituted Immediate Jeopardy (IJ) at F600. On April 25, 2025 at 5:26 PM, the survey team provided the Administrator and DON with a copy of the CMS IJ Template and informed the facility the IJ existed as of April 16, 2025. The IJ was related to §483.12 - Freedom from Abuse, Neglect, and Exploitation. [...]

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to report an allegation of potential non-consensual sexual abuse for Resident (R)2 by R1 to the proper authorities/state agency within the appropriate timeframes. On April 28, 2025 at 4:03 PM, the survey team notified the Administrator and DON that the failure to report an allegation of sexual abuse made by residents and staff constituted IJ at F609. On April 28, 2025 at 4:03 PM, the survey team provided the Administrator and DON with a copy of the CMS IJ Template and informed the facility the IJ existed as of April 16, 2025. The IJ was related to §483.12 - Freedom from Abuse, Neglect, and Exploitation. On April 28, 2025, the facility provided an acceptable IJ Removal Plan. [...]

Inspectors wroteBased on review of the facility policy and procedures, observations and interviews, the facility failed to maintain water temperatures within safe limits. This failure placed residents with access to hand sinks/showers at a potential risk for scalding injuries for three of three halls reviewed.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure 3 of 5 residents reviewed for dignity (Resident (R)3, R4, and R5) were treated in a manner that maintained and promoted their dignity and sense of safety after reporting or witnessing a potential non-consensual sexual encounter involving a non-interviewable resident (R2). Cross-Reference: F600 §483.12 Freedom from Abuse, Neglect, and Exploitation.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure Resident (R)1 was being monitored for the use of Psychotropic Medication, for 1 of 3 residents reviewed for chemical restraints.

Inspectors wroteBased on review of facility policy, interview, and record review, the facility failed to implement their abuse policies Abuse Investigation and Reporting and Abuse Prevention Program regarding an allegation of sexual abuse for 2 of 5 residents (Resident (R)1 and R2) reviewed for abuse. Specifically, the facility failed to investigate, report, prevent and or protect allegations of sexual abuse. Findings Include: Review of facility policy titled Abuse Investigation and Reporting last revised July 2017 revealed .5. The administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Role of the Investigator: 1. The individual conducting the investigation will, as a minimum: g. interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to serve foods palatable, safe, and at an appetizing temperature for six residents (Resident (R) 88, R1, R3, R6, R7, and R18) out of 31 sample residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to serve meals to the residents eating at the same table, at the same time, promoting dignity and well-being for three of four residents (Resident (R) 29, R4, and R88) of 31 sample residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a comprehensive care plan was developed for dementia for one of two residents (Residents (R) 28) sampled for dementia care.

Inspectors wroteBased on observations, interview, record review, and facility policy review, the facility failed to ensure residents who were dependent on staff for Activities of Daily Living (ADL) assistance received fingernail care services for one of three residents (Resident (R) R58) of 31 sample residents. This failure placed residents at risk for diminished self-worth, self-esteem, feelings of embarrassment, and/or medical issues.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure that one of three residents (Resident (R)13) reviewed for splinting of 31 sample residents received the orthotic devices ordered by the Physician. This practice has the potential for other residents to be at risk for decreased range of motion and/or worsening of their contracture.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure to document the resident's condition upon return from dialysis treatment for one of one resident (Resident (R)52) reviewed for dialysis care. As a result of this deficient practice potential hemodynamic instability could go unnoticed and compromise the care of the dialysis resident after treatment.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents on psychotropic medications were adequately monitored for side effects, behaviors, and results documented for two of five residents (Resident (R) 28 and R6) reviewed for unnecessary medications of 31 sample residents. As a result of this deficient practice residents on antipsychotic medications not being monitored for behaviors may be over or under medicated.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure that one of two refrigerators and sinks during observations of one of two medication rooms were cleaned for 94 census residents.

Inspectors wroteBased on observations, record review, interviews, and review of the facility policy titled, Elopement and Wandering Residents, the facility failed to ensure neglect did not occur by providing adequate supervision to prevent elopement. Resident (R)26 exited the facility on June 27, 2021 at 4:20 PM unassisted. A nursing staff member identified a man coming up the road with his walker toward the stop sign of [NAME] road, street frontage, as R26. On 10/28/21 at 4:07 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were notified that the facility neglected to provide adequate supervision to prevent elopement for Resident (R) 26. R26 had a successful elopement from the facility on June 27, 2021. R26 was found walking down the street with a walker by a member of the facility staff. R26 was unharmed and did not obtain any injuries. [...]

Inspectors wroteBased on observations, record review, interviews, and review of the facility policy titled, Elopement and Wandering Residents, the facility failed to provide adequate supervision to prevent elopement. Resident (R)26 exited the facility on June 27, 2021 at 4:20 PM unassisted. A nursing staff member identified a man coming up the road with his walker toward the stop sign of [NAME] road, street frontage, as R26. On 10/28/21 at 4:07 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were notified that the facility neglected to provide adequate supervision to prevent elopement for Resident (R) 26. R26 had a successful elopement from the facility on June 27, 2021. R26 was found walking down the street with a walker by a member of the facility staff. R26 was unharmed and did not obtain any injuries. [...]

Inspectors wroteBased on staff and resident interviews, observations, and review of the facility's policy, it was determined the facility failed to provide personal privacy for 12 of 12 residents who attended the Resident Council interview (Resident (R) 9, 6, 10, 19, 21, 42, 47, 49, 68, 69, 81 and 437) when making phone calls from the phone provided by the facility. This failure had the potential to create an undignified existence for the 12 residents who voiced they were unable to carry on private telephone conversations.

Inspectors wroteBased on record review, interviews and review of the facility policy titled, Advance Directives, the facility failed to ensure Resident #70 and Resident #7 were afforded the right to formulate an Advance Directive for 2 of 3 residents reviewed for Advance Directives.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to implement the policy for abuse for 2 of 5 Residents (R) (R52 and R79) being reviewed for abuse.

Inspectors wroteBased on interviews, record reviews and review of the facility's abuse policy, the facility failed to report alleged violations in a timely manner for 2 of 5 Residents (R) (R52 and R79) being reviewed for abuse.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that all alleged violations involving abuse were thoroughly investigated for two (Resident (R) 52 and R79) of five residents reviewed for abuse. The facility had multiple incidents of alleged abuse for R79 and one incident of alleged abuse for R52 that were not properly investigated. This failure had the potential to contribute to the lack of prevention of abuse and protection of the residents from harm and abuse.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide the Pre-admission Screening and Annual Resident Review (PASARR) for mental illness (MI) and intellectual disability (ID) for 1 out of 19 residents reviewed during the initial pool.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive, person-centered Care Plan addressing the use of antipsychotic medication for one (Resident (R) 46) of five residents reviewed for Unnecessary Medications. This failure created a potential for inconsistent monitoring and inadequate behavior and medication management for R46.

Inspectors wroteBased on observations, interviews and review of the facility policy titled, Procedure: Guidelines for Cleansing and Observing a Wound, the facility failed to follow a procedure to ensure proper wound care for Resident #24 for 1 of 3 resident's reviewed for pressure ulcers.

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and implement a nutrition prevention intervention plan to prevent significant weight loss for one of one sampled resident, Resident (R) 25, reviewed for nutrition.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Psychotropic Medication, the facility failed to ensure two (Residents (R) 46 and R3) of five residents reviewed for Unnecessary Medications was free from unnecessary antipsychotic medication use. The failure to ensure adequate indication for use and adequate monitoring for effectiveness of antipsychotic medication placed R46 at potential of adverse side effects of using unnecessary antipsychotic medication.

Inspectors wroteBased on observations, interviews, and review of the facility policy titled, Medication Administration - General Guidelines, the facility failed to ensure a medication administration error rate of less than 5% for 5 out of 28 opportunities for errors. The medication error rate was 17.86%.

Inspectors wroteBased on observations, interviews, and review of information from the Institute of Safe Medical Practice, the facility failed to ensure Resident (R) 286, R285, and R70 were free from significant medication errors for 3 residents receiving medications for 5 out of 28 opportunities for error.

Inspectors wroteBased on observations, interviews, and review of the facility policy titled, Storage of Medications, the facility failed to remove an expired medication from 1 of 3 medication rooms.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure the electronic Medication Administration Record (MAR) was complete and accurate for one (Resident (R) 52) of 19 residents whose medical records were reviewed. Specifically, staff did not document the administration of controlled medications on the MAR to reflect actual usage by the resident or accurately document her pain rating on the MAR. This failure had the potential to contribute to drug diversion and the potential to lead to inadequate pain control for R52.

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to maintain and ensure the call light system was properly working for one (Resident (R) 57) of 19 residents reviewed for functioning call lights. This failure had the potential to delay staff response in the event of an emergency or unmet need.