St Andrews Health Campus

In the surveyor’s words

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

• Actual harm, isolatedF689Feb 22, 2023

  Based on interview and record review, the facility failed to transfer a resident appropriately resulting in a fracture for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: The clinical record for Resident B was reviewed on 2/20/23 at 2:38 p.m. A Quarterly MDS (Minimum Data Set) assessment, dated 2/2/23, indicated the resident was severely cognitively impaired. The resident required extensive assistance of two or more staff for mobility, transfer, and ADLs (Activities of Daily Living). She was always incontinent of bladder and frequently incontinent of bowel. The diagnoses included, but were not limited to, dementia, bone density and structure disorder, and abnormal posture. […]

• No harm, potential for more than minimal, widespreadF812Jan 15, 2026

  Based on observation and interview, the facility failed to store food items for residents appropriately related to expired foods for 1 of 2 kitchen observations. This deficient practice had the potential to affect 57 of 57 resident that reside in the facility. Findings include:During the initial kitchen tour and interview with the Dietary Manager (DM), on 01/08/2026 at 10:30 A.M., the following was observed: -Two plastic packages of sliced turkey deli meat with an expiration date of November 2025, were laying on the top shelf of a wheeled cart. The DM indicated it had been frozen and was recently thawed. They were going to use it for lunch. There was no date on the packages as to when the packages of turkey were thawed. […]

• No harm, potential for more than minimal, patternF641Dec 14, 2022

  Based on interview and record review, the facility failed to accurately complete MDS (Minimum Data Set) assessments related to anticoagulant medications for 5 of 18 residents reviewed for accuracy of assessments. (Residents 48, 39, 36, 37, and 34) Findings include: 1. The clinical record for Resident 48 was reviewed on 12/13/22 at 3:16 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 11/25/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, inflammatory liver disease, hypertension, and diabetes. The resident had received an anticoagulant for seven of seven days during the review period. […]

• No harm, potential for more than minimal, patternF684Dec 14, 2022

  Based on observation, interview, and record review, the facility failed to follow manufacturer's guidelines related to insulin pen usage (Resident 41); and follow physician's orders, ensure treatments were in place, and initiate monitoring of a wound (Residents 19, 28, and 48). for 4 of 17 residents reviewed for quality of care Findings include: 1. During a medication administration observation on 12/13/22 at 11:02 A.M., LPN (Licensed Practical Nurse) 10 prepared to administer Resident 41's routine and sliding scale insulin. LPN 10 removed the Novolog insulin pen from the medication cart and attached a capped needle to the pen. She held the pen sideways and indicated she was going to prime the pen. She dialed up 1 unit of insulin and pressed the button to expel the insulin. […]

• No harm, potential for more than minimal, isolatedF684Jan 15, 2026

  Based on record review, interview, and observation, the facility failed to follow physician's orders related to hold parameters for medications and identify skin impairments in a timely manner for 3 of 17 residents reviewed for Quality of Care. (Residents 8, 52, and 43)Findings include:1.The clinical record for Resident 8 was reviewed on 01/09/2026 at 1:15 P.M. An Annual Minimum Data Set (MDS) assessment, dated 10/10/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Parkinson's disease, hypertension, dementia, anxiety, and depression. The Electronic Medication Administration Record (EMAR) for November and December 2025, were provided by the Director of Nursing (DON) on 01/14/2026 at 1:05 P.M. […]