St Andrews Operator, LLC

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Apr 29, 2025

  Based on interview, record review, and facility policy review, the facility failed to protect one non-interviewable, cognitively impaired Resident (R2) from a non-consensual sexual encounter with R1. Despite prior documentation of R1's inappropriate and unsafe behaviors toward female residents, the facility did not implement timely or adequate interventions to prevent further incidents. On April 25, 2025 at 5:26 PM, the Administrator and Director of Nursing (DON) were notified that the failure to protect Resident (R)2 from a non-consensual sexual encounter with R1 constituted Immediate Jeopardy (IJ) at F600. On April 25, 2025 at 5:26 PM, the survey team provided the Administrator and DON with a copy of the CMS IJ Template and informed the facility the IJ existed as of April 16, 2025. […]

• Immediate jeopardy, isolatedF609Apr 29, 2025

  Based on review of facility policy, record review, and interview, the facility failed to report an allegation of potential non-consensual sexual abuse for Resident (R)2 by R1 to the proper authorities/state agency within the appropriate timeframes. On April 28, 2025 at 4:03 PM, the survey team notified the Administrator and DON that the failure to report an allegation of sexual abuse made by residents and staff constituted IJ at F609. On April 28, 2025 at 4:03 PM, the survey team provided the Administrator and DON with a copy of the CMS IJ Template and informed the facility the IJ existed as of April 16, 2025. The IJ was related to §483.12 - Freedom from Abuse, Neglect, and Exploitation. On April 28, 2025, the facility provided an acceptable IJ Removal Plan. […]

• Immediate jeopardy, isolatedF600Oct 28, 2021

  Based on observations, record review, interviews, and review of the facility policy titled, Elopement and Wandering Residents, the facility failed to ensure neglect did not occur by providing adequate supervision to prevent elopement. Resident (R)26 exited the facility on June 27, 2021 at 4:20 PM unassisted. A nursing staff member identified a man coming up the road with his walker toward the stop sign of [NAME] road, street frontage, as R26. On 10/28/21 at 4:07 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were notified that the facility neglected to provide adequate supervision to prevent elopement for Resident (R) 26. R26 had a successful elopement from the facility on June 27, 2021. […]

• Immediate jeopardy, isolatedF689Oct 28, 2021

  Based on observations, record review, interviews, and review of the facility policy titled, Elopement and Wandering Residents, the facility failed to provide adequate supervision to prevent elopement. Resident (R)26 exited the facility on June 27, 2021 at 4:20 PM unassisted. A nursing staff member identified a man coming up the road with his walker toward the stop sign of [NAME] road, street frontage, as R26. On 10/28/21 at 4:07 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were notified that the facility neglected to provide adequate supervision to prevent elopement for Resident (R) 26. R26 had a successful elopement from the facility on June 27, 2021. R26 was found walking down the street with a walker by a member of the facility staff. […]

• Actual harm, isolatedF657May 9, 2022

  Based on facility policy, observations, record review, and staff interviews, the facility failed to adequately implement care plan interventions for one resident (R) 6 out of 3 reviewed for accidents. Specifically, R6 had an unwitnessed fall, sustained a facial fracture, which required sutures, and was readmitted to the facility with interventions related to falls. The failure to ensure the interventions in place were properly recorded and monitored by staff, placed the resident at risk for avoidable reoccurring injuries. Findings include: Review of the facility's policy titled Care Planning, effective July 2017, revealed I. […]