St Andrews

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 21, 2021

  Based on observation, interview, and record review, the facility failed to ensure one of 16 residents (Resident 1), who had behaviors of wandering (to walk aimlessly) and elopement (leaving unsupervised, undetected without authorization) had a risk for elopement and wandering assessment, care plan regarding elopement, and was monitored. Resident 1 eloped from the facility on [DATE] to the liquor store, across the street from the facility and was brought back to the facility by Licensed Vocational Nurse 1 (LVN 1). On [DATE], Resident 1 eloped form the facility a second time and was involved in a tragic incident. […]

• No harm, potential for more than minimal, patternF805Jun 5, 2026

  Based on observation, interview, and record review, the facility failed to ensure fortified diets (meal plan that increases a resident's caloric intake by adding high calorie items) were prepared as prescribed by the physician for five of 10 sampled residents (Resident 16, Resident 21, Resident 42, Resident 46, and Resident 51).This deficient practice had the potential for the residents not to meeting their nutritional needs.Findings:During a review of Resident 16's admission Record, the admission Record indicated the facility admitted the resident on 11/20/2025 with diagnoses including sepsis (a severe body wide infection that can lead to organ failure), unspecified protein-calories malnutrition (not getting enough calories and protein, leading to weight loss and weakness), vitamin D… […]

• No harm, potential for more than minimal, patternF812Apr 18, 2025

  Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety by failing to: 1. Ensure food items were labeled in Refrigerator 1, Refrigerator 2, Refrigerator 3 and Freezer 2 in the kitchen. 2. Ensure expired food was discarded from Refrigerator 2 in the kitchen. 3. Ensure a dented can sign was on display in the dry storage area. 4. Ensure the kitchen mixer and processer was clean. 5. Ensure the juice dispensing nozzle was clean. This deficient practice had the potential to result in in foodborne illness and contamination. […]

• No harm, potential for more than minimal, patternF838Apr 18, 2025

  Based on interview and record review, the facility failed to revise and provide an updated average daily census of the Facility Assessment Tool (a process for evaluating a facility's resident population and identifying the resources needed to provide care and services). This deficient practice had the potential to place residents at risk for delay of care and treatment services. Findings: During a review of the facility census for 4/15/2025, indicated 54 residents resided in the facility. During a concurrent interview and record review on 4/16/2025 at 8:21 a.m., with the Administrator (ADM), the Facility Assessment Tool, was reviewed. The ADM stated the Facility Assessment Tool was last updated on 12/6/2024. […]

• No harm, potential for more than minimal, patternF755Apr 28, 2024

  Based on observation, interview, and record review the facility failed to follow its policy and procedure to replace the non- antibiotic Emergency Kit (E-Kit) within 72 hours. This deficient practice had the potential for not providing medication to residents during emergency situations. Findings: During a concurrent observation and interview on 4/27/2024 at 10:10 a.m., of the medication storage room [ROOM NUMBER] with Licensed Vocational Nurse 2 (LVN 2), found one portable container non-antibiotic medication E-Kit with prescription #3187400, with red seal tag. LVN 2 stated the portable container non-antibiotic medication E-Kit indicates a fill date of 2/13/2024. LVN 2 stated red seal tag means the E-Kit had been opened. LVN 2 stated yellow seal tag means the E-Kit had not been opened. […]