St. Andrew Post-Acute Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at St. Andrew Post-Acute Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Sep 5, 2024

  Based on observations, interviews, and record review, the facility failed to store, prepare and follow professional standards for food service safety in two (main and satellite) of two kitchens, as evidenced by: 1. two trash cans were not sanitarily maintained; 2. food was not maintained for safe consumption to include improper food handling practices; 3. kitchen shelving used for storage of food was observed rusted/oxidized, 4. temperature logs for the refrigerator and freezer were not documented accurately, and 5. one staff member (Q) not donning a hairnet upon entry to the kitchen during two (9/3/24 and 9/5/24) of three days of the survey. Findings included: On 9/3/24 at 9:20 a.m. a tour of the facility's main kitchen was conducted with Staff M, Certified Dietary Manager (CDM). […]

• No harm, potential for more than minimal, patternF645Sep 5, 2024

  Based on observations, record reviews, and interviews the facility failed to ensure Pre-Admission Screening and Resident Reviews (PASRRs) for six residents (#2, #9, #10, #15, #27, and #28) out of twenty sampled residents were accurate at the time of admission and updated when necessary. Findings included: 1. Review of Resident #2's Admission Record revealed the resident was admitted on [DATE] and 8/19/24. The record included diagnoses not limited to unspecified recurrent major depressive disorder (onset 3/27/22), generalized anxiety disorder (onset 4/25/22), and unspecified insomnia (7/23/22). […]

• No harm, potential for more than minimal, patternF677Sep 5, 2024

  Based on observations, staff and resident interviews, and record review, the facility failed to provide three of twenty sampled residents (#15, #10, and #28) with activities of daily living related to showers/baths (#10, #15) and personal hygiene related to shaving (#15) and eating assistance (#28) as per their request and scheduled timeframes. Findings included: 1. On 9/3/2024 at 10:00 a.m. Resident #15 was heard yelling out and moaning aloud from behind her closed room door. During an interview at this time, the resident stopped yelling aloud and revealed she wanted staff to come and take her to the shower. She revealed she yells out rather than uses the call light, because they (staff) respond faster. […]

• No harm, potential for more than minimal, patternF880Sep 5, 2024

  Based on observations, interviews and record review the facility failed to implement and maintain an infection prevention and control program to mitigate the spread of infection related to staff not offering hand hygiene to residents prior to a meal and two staff members (R, and G) not performing hand hygiene with the potential to affect a census of 41 residents. Findings included: On 9/3/24 observations of the lunch service in the dining room from 11:51 a.m. to 12:55 p.m. revealed no hand hygiene was offered to multiple residents prior to eating. At 12:01 p.m. Staff E, Registered Nurse (RN) entered the dining room area. At 12:27 p.m. […]

• No harm, potential for more than minimal, patternF695Sep 9, 2022

  Based on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided according to professional standards of practice for three (#19, 28, 146) out of four residents sampled. Findings Included: 1. On 09/06/22 at 12:33 p.m. Resident #19 was observed sitting in her wheelchair in her bedroom, and smiled when approached. Resident #19 stated I can't leave my room as she pointed to her nose that contained oxygen tubing. The tubing was attached to concentrator, which was turned on and registered at 2 liters. The tubing reflected the date 08/24/2022. Additionally on the bedside table a small volume nebulizer machine was observed with the tubing and mask dated 08/24/2020. […]