St Andrew's at Francis Place

In the surveyor’s words

From the most serious findings on record at St Andrew's at Francis Place, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Aug 16, 2023

  Based on observation, interview and record review, the facility failed to prevent and treat pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one resident (Resident #1) admitted to the facility on [DATE] with redness to the buttocks. On [DATE], a skin assessment showed a 2.5 centimeter (cm) x 1 cm open area. The area was not staged and no wound description was documented. The physician was not notified and no treatment was documented as applied. On [DATE], staff added a treatment to the Treatment Administration Record (TAR), but did not obtain a treatment order from the physician. On [DATE], an order for the specialized wound management clinic was obtained, but the resident was not added to the facility wound report tracking record. […]

• Immediate jeopardy, isolatedF684Jul 13, 2021

  Based on interview and record review, the facility failed to provide acceptable nursing standards of care for one of seven sampled residents (Resident #1). The resident was left in a raised bed with an air mattress on top of the regular mattress and fell on to the floor. The resident had notable bleeding, facial lacerations and bruising. Staff failed to assess the resident on the floor and moved him/her back into the bed and failed to perform and document neurological assessments, vital signs or pain assessments. Staff failed to report a change in mental status to the physician in a timely manner. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The census was 87. […]

• Actual harm, isolatedF561Nov 19, 2025

  Based on observation, interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) D, an agency CNA, respected Resident #24's right to remain in bed. On 10/2/25, the CNA transferred the resident out of bed for a shower after the resident told the CNA he/she did not want to get out of bed. The resident said he/she was upset about being made to get up, the transfer was rough and felt like a tussle. During the transfer, the resident sustained a large skin tear, approximately ten centimeters (cm) long, to the left lower leg. The resident was sent to the hospital where five sutures were required to close the skin tear. The facility investigated the incident and in-serviced some nursing staff on transfer training. […]

• Actual harm, isolatedF697Aug 16, 2023

  Based on observation, interview and record review, the facility failed to ensure pain assessments and pain management were provided consistent with professional standards of practice, by failing to ensure a resident who developed a large coccyx (tailbone) pressure ulcer and expressed pain was assessed timely and accurately (Resident #1). The sample was 5. The census was 101. Review of the pain management policy, revised ,d+[DATE], showed: -Policy: As advocates for the elderly, we are committed to assure that the residents do not suffer needlessly from pain. We believe our residents have the right to have their pain assessed and continuously and appropriately managed within the frame work of psychosocial and physical adaptations. […]

• No harm, potential for more than minimal, patternF688Aug 29, 2025

  Based on observation, interview and record review, the facility failed to ensure residents designated to receive walk to dine restorative services (staff assist residents to walk to and/or from the dining room daily at breakfast, lunch or dinner) received that restorative service. The facility identified 22 residents on the walk to dine program. Of those 22, five were interviewable and all five said staff did not walk them to and/or from the dining room for any of the three meals (Residents #18, #9, #21, #2 and #19). […]