Gregory Wing of St Andrews Village

In the surveyor’s words

From the most serious findings on record at Gregory Wing of St Andrews Village, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF909May 15, 2024

  Based 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. Findings: On 5/14/24 at 11:42 a.m., a surveyor met with the Director of Facilities and asked for the bed gap measurements and side rail gap measurement documentation. The Director of Facilities stated that he had never heard of those before and he would check with the other maintenance men. He came back and stated that they had never heard of them either. At this time, the Director of Facilities confirmed that the facility had never completed bed gap measurements and/or side rail gap measurements at the facility for any of the resident's beds. […]

• No harm, potential for more than minimal, patternF584Aug 15, 2025

  Based 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 findings:Laundry: - There was a ceiling tile, over the stackable dryers, that was broken and had fallen out of place. - The entire floor was dirty and heavily soiled with dirt. - There were approximately 10 cracked/broken floor tiles throughout the laundry room. […]

• No harm, potential for more than minimal, patternF657Aug 15, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF695Aug 15, 2025

  Based 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). […]

• No harm, potential for more than minimal, patternF812Aug 15, 2025

  Based 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. […]