The Springs at St. Andrews Village

In the surveyor’s words

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

• Actual harm, isolatedF697Mar 26, 2026

  Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for two (#74 and #71) of five residents reviewed for pain management out of 32 sample residents. Resident #74 was admitted to the facility from the hospital on 3/22/26, after treatment for sepsis (life threatening condition) from a vertebral (spinal) infection resulting in severe pain in her spine. After the resident's admission to the facility, the facility failed to ensure the resident's prescription for oxycodone was sent to the pharmacy timely so the pain medication could be received and administered. […]

• Actual harm, isolatedF689Aug 18, 2022

  Based on record review, observations, and staff interviews, the facility failed to ensure two (#5 and #2) of three residents reviewed for accident hazards out of six sample residents, were provided adequate supervision and a safe environment to prevent accidents. Resident #5 was admitted to the facility on [DATE] with a history of falls. The resident had ten falls from 4/19/22 through 8/7/22. The facility failed to implement effective fall precautions with his risk of falling. On 4/21/22 the resident sustained a head injury following a fall which required hospital treatment. Observations on survey from 8/17/22 to 8/18/22 revealed fall measures were not consistently implemented. In addition, the facility failed to ensure Resident #2 had all interventions in place to prevent falls. […]

• Actual harm, isolatedF686Mar 23, 2022

  Based on observations, record review, and interviews, the facility failed to provide care and services to prevent the development and worsening of pressure injuries for two (#1 and #3) residents reviewed out of five sample residents. The facility failed to implement a care plan and monitor for worsening skin integrity for Resident #1 and #3 with interventions to prevent the development of pressure injuries even though the residents were high risk. The facility staff had identified redness and excoriation in Resident #1's weekly skin assessment on [DATE] on the resident's groin but did not document an assessment of the area until [DATE] and did not implement any interventions to prevent further breakdown from occurring. […]

• Actual harm, isolatedF697Oct 11, 2021

  Based on interviews and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#1) of three residents reviewed for pain management out of eight sample residents. The facility failed to ensure pain medications were obtained on admission or timely thereafter for Resident #1, who was admitted to the facility from the hospital for aftercare for laminectomy and facetectomy both lumbar and [MEDICATION(S)] (spinal surgery). […]

• Actual harm, isolatedF692Aug 24, 2021

  Based on record review and interviews, the facility failed to ensure one (#17) of three residents reviewed for nutritional status out of 20 sample residents maintained acceptable parameters of nutritional status such as usual body weight or desirable body weight. Specifically, the facility failed to implement interventions to prevent a significant weight loss for Resident #17 with nutritional risks including poor nutritional intake and requiring staff assistance for cueing at meals, and was not outlined on her comprehensive care plan. The resident had a weight loss of nine pounds over a period of one month, which was 5%, considered significant weight loss. The weight loss was not addressed timely with her family since the resident had cognitive impairments. […]