Andrew Residence

In the surveyor’s words

From the most serious findings on record at Andrew Residence, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 30, 2026

  Based on observation, interview, and document review, the facility failed to ensure hazards were removed for R1 per their care plan and failed to provide R2 with the necessary supervision to prevent elopement after being care planned to require supervision in the community. These failures resulted in Immediate Jeopardy (IJ) for two of two residents when R1 attempted suicide after identified care plan interventions were not thoroughly implemented and when R2 left the facility multiple times without staff knowledge with an increase in suicidal ideation and in dangerously high temperatures. […]

• Immediate jeopardy, isolatedF610Nov 25, 2025

  Based on interview, observation, and record review the facility failed to immediately respond, investigate timely, and implement resident protections for 4 of 4 residents (R1, R2, R3, R4) after an allegation of sexual abuse of R1 by R2 was reported, which resulted in subsequent sexual abuse for R3 and R4. The immediate jeopardy began on 11/7/25 at 1:30 p.m., when R1's family member (FM)-A reported unwanted sexual touching, by R2 to R1 while the residents were in R1's room, to the Social Worker (SW)-A and the facility failed to timely report the incident to the State Agency, begin an investigation, and place resident protections to ensure other vulnerable residents at risk of sexual abuse were safe. […]

• Immediate jeopardy, isolatedF600Nov 2, 2021

  Based on observation, interview and document review, the facility failed to identify and implement interventions for R2 upon admission who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 sexually abused R1 and R3. R1 experienced psychosocial harm as a result of the abuse. The IJ began on 9/20/21, when the facility failed to identify and implement interventions to protect residents when admitting R2 who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility administrator, director of nursing (DON), and director of program services were notified of the IJ on 10/29/21, at 4:47 p.m. The IJ was removed on 11/2/21, at 11:37 a.m. […]

• Actual harm, isolatedF699Aug 3, 2023

  Based on observation, interview and document review the facility failed to ensure specific triggers for post-traumatic stress disorder (PTSD) were comprehensively reassessed and care planned for, including medical and psychiatric interventions. This resulted in repeated seizures, numerous falls with head strikes and hospitalization s for 1 of 1 resident (R179) reviewed for trauma informed care. Findings include: R179's Record of Admission indicated R179 was admitted to the facility on [DATE] with several medical diagnoses to include bipolar disorder (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder, PTSD (a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological… […]

• No harm, potential for more than minimal, widespreadF812Aug 26, 2026

  Based on observation, interview, and document review, the facility failed to ensure the proper use of beard restraints during food preparation and meal service. This had the potential to affect all 191 residents who received food from the kitchen.Findings include:During observation and interview on 8/26/26 at 7:15 a.m., cook (C)-A was observed to have gray whiskers covering his chin and lower cheeks which were approximately 1/2 inch in length. He took the temperatures of oatmeal and scrambled eggs without wearing a beard restraint. When asked about beard restraints, C-A stated, Am I supposed to be wearing one?. […]