The Springs at St. Andrews Village

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for two (#74 and #71) of five residents reviewed for pain management out of 32 sample residents. Resident #74 was admitted to the facility from the hospital on 3/22/26, after treatment for sepsis (life threatening condition) from a vertebral (spinal) infection resulting in severe pain in her spine. After the resident's admission to the facility, the facility failed to ensure the resident's prescription for oxycodone was sent to the pharmacy timely so the pain medication could be received and administered. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper storage of medications for one of four medication storage rooms and two of four medication storage carts. Specifically, the facility failed to:-Ensure eye drops were dated with the date they were opened;-Ensure medications were contained in the original packaging; and,-Ensure expired medical supplies were discarded.

Inspectors wroteBased on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for three (#19, #74 and #75) of 10 residents reviewed for dignity out of 32 sample residents. Specifically, the facility failed to ensure Resident #19, Resident #74 and Resident #75 had the right to a dignified existence by being provided privacy in their personal bathrooms.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that the residents had a safe, clean, comfortable, and homelike environment for three out of 12 rooms. Specifically, the facility failed to ensure the facility's process of reporting and responding to repairs in the resident's rooms was being utilized to maintain three damaged closets in Resident #8, Resident #74, and Resident #33's rooms.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure three (#30, #55 and #71) of eight residents received treatment and care in accordance with professional standards of practice out of 32 sample residents. Specifically, the facility failed to:-Ensure physician's orders for post-void residual measurements (PVR - measures the amount of urine remaining in the bladder immediately after urination) were followed for Resident #71;-Ensure physician's orders were in place for a wound dressing for Resident #55; and,-Ensure Resident #30 received wound prevention care in accordance with the physician's orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%). Specifically, the facility had a medication error rate of 13.33%, or four errors out of 30 opportunities for error.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#74, #43 and #55) of eight residents reviewed for medication management were free from significant medication errors out of 32 sample residents. Specifically, the facility failed to:-Ensure Resident #74 received scheduled intravenous (IV) antibiotics as ordered; and, -Ensure Resident's #43 and #55's blood pressure medications were administered or held per physician ordered parameters.

Inspectors wroteBased on observations and interviews, the facility failed to ensure mechanical equipment was in safe, operational condition. Specifically the facility failed to ensure one of three washing machines in the facility's laundry room was in appropriate operational condition.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, sanitary, functional and comfortable environment for the residents. Specifically the facility failed to:-Ensure one of four resident shower rooms was free of deterioration and water damage and had a properly operational shower head;-Ensure resident room corridors were free of deterioration and water damage;-Ensure one of 12 resident rooms had a properly operational sink faucet; and, -Ensure two of 12 resident personal bathrooms were free of deterioration and water damage.

Inspectors wroteBased on observations and interviews, the facility failed to ensure adequate outside ventilation by means of windows, or mechanical ventilation for three out of 12 residents' personal bathrooms. Specifically, the facility failed to ensure ventilation fans were kept operational in the resident personal bathrooms.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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 the medication cart.

Inspectors wroteBased 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 touch surfaces were cleaned.

Inspectors wroteBased on record review, and interviews, the facility failed to ensure immediate physician notification for one (#122) of three residents reviewed out of 26 sample residents. Specifically the facility failed to ensure the physician was notified of Resident #122's high blood sugar/glucose level readings that were out of physician ordered parameters.

Inspectors wroteBased on record review and interviews, the facility failed to ensure treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#9) of three residents reviewed for quality of care out of 26 sample residents. Specifically, the facility failed to follow physician orders for Resident #9: -Humaglog solution (insulin) was not administered although the physician orders documented to administer if the fasting blood glucose was greater than 180; and, -Follow the physician orders six times when the blood sugar/glucose level readings were out of physician ordered parameters.

Inspectors wroteBased on observations and interviews the facility failed to establish and maintain infection control designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for two of three units. Specifically the facility failed to: -Ensure proper hand hygiene was performed between residents during medication administration; and, -Ensure multiple use medical equipment was sanitized between residents.

Inspectors wroteBased on record review and interviews the facility failed to provide ostomy care to one resident (#122) of one resident reviewed out of 26 sample residents. Specifically, the facility failed to: -Ensure physician orders were in place to provide colostomy care for Resident #122; and, -Ensure there was a comprehensive care plan for colostomy care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents were free of unnecessary psychotropic medications for one (#9) of three residents reviewed for unnecessary medication out of 26 sample residents. Specifically, the facility failed to: -Track hours of sleep to evaluate the effectiveness of an antidepressant (Trazodone) being utilized as a hypnotic for the diagnosis of insomnia for Residents #9; -Have a physician's order to track and monitor hours of sleep for Resident #9; and, -Have non-pharmacological interventions on plan of care for insomnia for Resident #9.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure drug and biologics were labeled and stored correctly in one of three units. Specifically the facility failed to: -Ensure narcotics were stored properly; and, -Ensure opened vial of influenza vaccines were dated upon opening. Findings Include: I. Professional reference According to the Afluria package insert, retrieved 12/19/22 from: https://www.fda.gov/media/81559/download, Once the stopper of the multi-dose vial has been pierced the vial must be discarded within 28 days. II. Facility policy and procedures The Controlled Substance policy, undated, received from the director of nursing (DON) on 12/14/22 at 2:49 p.m., revealed in pertinent part, only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule two controlled drugs on premises. [...]