St Andrews Bay Skilled Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at St Andrews Bay Skilled Nursing and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF676Feb 24, 2026

  Based upon observations, interviews, and record reviews, the facility failed to provide Activities of Daily Living (ADLs) to maintain or improve abilities and choices for 5 out of 10 residents reviewed. (Resident #1, #6, #8, #9, #10)The findings include:On 2/23/26 at 10:15 AM, a tour of the facility was conducted. The following observations were made:Resident #6's room door was open and no privacy curtain was in use. The resident was lying in bed awake screaming I'm hurting. Resident #6 appeared unshaven and his hair was unkempt. He appeared to be restless moving in bed from side to side while rubbing his right and left lower legs. He did not have any clothes on except for an incontinence brief. He did not have any sheets or blankets over him. […]

• No harm, potential for more than minimal, patternF919Feb 24, 2026

  Based upon observations, interviews, and record reviews, the facility failed to ensure call lights were placed within reach of dependent residents while in their rooms for 12 out of 116 resident beds observed. (Rooms 115, 207, 208 (both A and B beds), 212, 213, 215, 302, 303, 308, 402, and 409)The findings include:A tour of the facility was conducted on 02/23/26 at 10:15 AM and revealed the following call light issues:In room [ROOM NUMBER], the call light was fastened with a red plastic clip hanging in between the bed and bedside dresser, out of reach of the resident lying in bed. […]

• No harm, potential for more than minimal, isolatedF690Sep 3, 2026

  Based on observation, record review, interview, and policy review, the facility failed to provide adequate and appropriate treatment and services related to the management of an indwelling urinary catheter to prevent urinary tract infection and hospitalization for 1 of 1 resident reviewed for urinary catheter care (Resident #112).The findings included:During tours of the facility conducted on 09/01/2026 at 8:47 AM, 2:40 PM, and 4:13 PM, it was observed that Resident #112's urinary catheter drainage bag was dated 08/15/2026 (Photographic evidence obtained). […]

• No harm, potential for more than minimal, isolatedF732Sep 3, 2026

  Based upon observations and interviews, the facility failed to post the daily staffing information in a manner that was readily available to staff, residents, and visitors for 3 out of 4 consecutive days.The findings include:An observation of the daily staffing data posted for public view was conducted on 08/31/2026 at 11:30 AM and again at 03:00 PM. The staffing data displayed was dated 08/30/2026, indicating that the information was not updated for the current day.On 09/01/2026, observations were conducted of the staffing data at 08:15 AM, 11:30 AM, 02:15 PM, and 04:30 PM. The information posted remained dated 08/31/2026, again reflecting failure to update the daily staffing posted.On 09/02/2026, observations were conducted of the posted staffing data at 08:00 AM and 11:00 AM. […]

• No harm, potential for more than minimal, isolatedF686Feb 24, 2026

  Based upon interviews and record reviews, the facility failed to ensure 1 of 3 residents reviewed for wound care received ongoing monitoring and treatment for wound care to prevent worsening and new pressure ulcers from occurring, initiate treatment orders on admission, and monitor bruising to left lower abdomen, left groin and thigh that resulted in worsening of wounds and bruising. (Resident #1)The findings include:On 2/23/26 at 2:00 pm, an interview was conducted with Resident #1 who revealed upon admission on [DATE] that she did not have any wounds except on her sacral area but now she has a wound on her heel.A record review was conducted on 2/23/26 for Resident #1. […]