Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St. Andrew Post-acute Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain sanitary conditions and adhere to professional standards for food service safety in both the main and satellite kitchens. Observations revealed unsanitary conditions, improper food handling, and inaccurate temperature documentation. Staff members were observed not wearing hairnets or gloves, and food items were improperly stored and labeled. The facility's policies on food receiving, preparation, and storage were not followed, leading to the observed deficiencies.
The facility failed to ensure accurate and updated PASRRs for six residents, leading to deficiencies in identifying mental illnesses and intellectual disabilities. Several residents had diagnoses such as major depressive disorder and dementia, yet their PASRRs did not reflect these conditions, and necessary Level II evaluations were not conducted. The Social Service Director acknowledged the need for updates and corrections in the PASRR process.
The facility failed to provide adequate assistance with ADLs for three residents, leading to deficiencies in personal hygiene and care. One resident missed scheduled showers and had long facial hair, another did not receive showers on multiple days, and a third had long, splitting fingernails. Staff interviews revealed issues with staffing and documentation, contributing to unmet needs.
The facility failed to maintain an effective infection prevention and control program, as staff did not offer hand hygiene to residents before meals and did not perform hand hygiene during meal service. A RN assisted residents with dining without hand hygiene, and a Dietary Aide handled food without gloves or hand hygiene, violating the facility's policy.
A resident receiving IV antibiotics for a wound infection experienced repeated alarms from the IV therapy system due to 'air in the line,' indicating medication was not being delivered. Despite the alarm being audible from the hallway, staff response was delayed, with the resident calling for assistance multiple times. Interviews revealed staff were unaware of the resident's IV therapy details, and there was no documentation of concerns in the nurse progress notes, indicating a failure to adhere to the facility's IV therapy procedures.
A resident with a history of shortness of breath was not properly monitored for oxygen saturation levels as required by physician orders. The facility's records showed inconsistencies in documenting the resident's care, including the elevation of the head of the bed and the administration of oxygen. Despite a policy requiring vital signs to be recorded, the Treatment Administration Records lacked a section for documenting oxygen saturation levels, leading to a deficiency in respiratory care.
A long-term care facility experienced a 25% medication error rate during an observation, involving two residents. Errors included administering medications from another resident's supply, failing to administer prescribed medications due to unavailability, and not obtaining required vital signs before medication administration. The facility's policies on medication administration and communication with physicians were not followed, contributing to the deficiency.
Sanitation and Food Handling Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to maintain sanitary conditions and adhere to professional standards for food service safety in both the main and satellite kitchens. Observations revealed unsanitary conditions, including trash cans with overflowing refuse and sticky substances, and improper food handling practices. In the main kitchen, a staff member handled wilted and damaged cabbage with ungloved hands, dropped it on the soiled refrigerator floor, and returned it to the box without washing or discarding it. Additionally, a honeydew melon with mold was cut and intended for consumption, and the cutting board was left with black residue from the mold. Further deficiencies were noted in the storage and labeling of food items. The walk-in refrigerator contained uncovered and improperly stored food, such as a sheet cake and rusted shelving without barriers between the shelves and food items. The walk-in freezer had uncovered pie crusts that were not labeled or dated. Temperature logs for the refrigerator and freezer were not accurately documented, and staff members were observed not wearing hairnets or gloves during food preparation and handling. The facility's policies on food receiving, preparation, and storage were not followed, as evidenced by the lack of proper cleaning and sanitizing of equipment and work surfaces. The Registered Dietitian confirmed that moldy produce should be discarded and that food dropped on the floor should not be reused. The facility's failure to adhere to these policies and maintain sanitary conditions led to the observed deficiencies.
Inaccurate and Outdated PASRRs for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate and updated Pre-Admission Screening and Resident Reviews (PASRRs) for six residents at the time of admission. Resident #2 was admitted with diagnoses including major depressive disorder, generalized anxiety disorder, and insomnia, yet their PASRR indicated no mental illness or intellectual disability, and a Level II PASRR was not conducted. The Social Service Director (SSD) acknowledged that the PASRR should have been redone. Similarly, Resident #9's PASRR did not reflect the need for a Level II evaluation despite having a primary diagnosis of serious mental illness and dementia, which the SSD confirmed should have been completed. Resident #10 was admitted with a primary diagnosis of dementia and other mental health issues, but their PASRR did not indicate any mental illness or intellectual disability, and a Level II evaluation was not performed. The SSD confirmed that a Level II PASRR should have been conducted. Resident #15's PASRR did not include a diagnosis of major depression, despite the resident having multiple mental health diagnoses, including schizoaffective disorder. The SSD confirmed the PASRR was incomplete and should have been updated. Residents #27 and #28 both had diagnoses of major depressive disorder, yet their PASRRs did not document these qualifying mental health diagnoses. The SSD acknowledged that the PASRRs for both residents needed updating to reflect their current mental health conditions. The facility's policy requires the Social Services Director to track each resident's PASRR status and ensure coordination with the PASRR program, which was not adequately followed in these cases.
Deficiencies in ADL Assistance and Documentation
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in personal hygiene and care. Resident #15, who was dependent on staff for bathing and personal hygiene, repeatedly missed scheduled showers and was observed with disheveled hair and long facial hair. Despite expressing her discomfort and requesting assistance, the resident did not receive timely care, and there was no documentation of missed showers or refusals in her medical records. Staff interviews revealed a lack of sufficient staffing and documentation issues, contributing to the resident's unmet needs. Resident #10, who also required assistance with bathing, did not receive showers on multiple scheduled days. The facility's records lacked documentation of completed showers or refusals, and staff interviews indicated a problem with documentation practices. The resident's care plan specified the need for assistance with bathing, but the facility failed to ensure compliance with the care plan, resulting in missed showers. Resident #28 experienced issues with nail care, as his fingernails were observed to be long and splitting. Although the resident's care plan included interventions for nail care, staff interviews and progress notes revealed inconsistencies in documentation and care provided. The resident expressed a preference for shorter nails, but staff reported challenges in obtaining consent for nail trimming. The facility's documentation practices and communication among staff contributed to the deficiency in providing necessary nail care.
Inadequate Hand Hygiene Practices During Meal Service
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by staff not offering hand hygiene to residents prior to meals and staff members not performing hand hygiene during meal service. Observations on 9/3/24 during lunch service revealed that multiple residents were not offered hand hygiene before eating. Staff E, a Registered Nurse, was observed assisting residents with dining without performing hand hygiene before or after handling utensils, serving beverages, or feeding residents. This lack of hand hygiene was consistent throughout the lunch service, affecting the residents' dining experience. Additionally, on 9/4/24, Staff G, a Dietary Aide, was observed in the satellite kitchen testing and recording food temperatures without practicing hand hygiene. Staff G handled food items and surrounding surfaces without using gloves or performing hand hygiene, which is a breach of the facility's infection prevention and control policy. The facility's policy, last revised in July 2023, mandates maintaining a safe and sanitary environment to prevent the transmission of infections, which was not adhered to in these instances.
Failure in IV Medication Administration
Penalty
Summary
The facility failed to provide proper administration of intravenous (IV) medication in accordance with professional standards for a resident. On multiple occasions, the IV therapy system alarmed due to 'air in the line,' indicating that the medication was not being delivered to the resident. The resident, who was receiving IV antibiotics for a wound infection, expressed frustration over the frequent alarms and the delayed response from staff. Observations confirmed that the alarm was audible from the hallway, yet staff response was delayed, with the resident calling out for assistance multiple times before a nurse attended to the issue. Interviews with staff revealed a lack of awareness regarding the resident's IV therapy details, such as the duration of treatment and the specific medication being administered. Staff A, a Registered Nurse/Unit Manager, and Staff O, a Licensed Practical Nurse, both acknowledged that only IV-trained nurses could address the air in the line issue. However, there was no documentation in the nurse progress notes regarding any concerns with the IV therapy system or any refusal of therapy by the resident, indicating a gap in communication and documentation practices. The facility's policy on intravenous therapy outlined procedures for ensuring air is removed from the tubing before administration, yet the repeated alarms suggest these procedures were not consistently followed. The policy also emphasized the need for documentation in the nurses' notes or Medication Administration Record, which was not evident in the review of the resident's records. This deficiency highlights a failure in adhering to the facility's own standards and procedures for IV therapy administration.
Failure to Monitor Oxygen Saturation Levels
Penalty
Summary
The facility failed to adequately monitor the oxygen saturation levels for a resident who required respiratory care. On observation, the resident was found lying in bed with an oxygen concentrator nearby, but there was no documentation of oxygen saturation levels being recorded as per the physician's orders. The resident's medical records indicated a history of shortness of breath, and the care plan included interventions for oxygen therapy related to shortness of breath when lying flat. However, the Medication Administration Record (MAR) and Treatment Administration Records (TAR) showed inconsistencies in documenting the resident's head of bed elevation and lacked specific documentation of oxygen saturation levels, despite checkmarks indicating administration. The facility's policy on medication administration required staff to obtain and record vital signs when applicable or per physician's orders, and to document these on the MAR. Despite this, the TAR did not provide a space for recording oxygen saturation levels, and staff only marked checkmarks without actual saturation readings. The Director of Nursing confirmed that staff should document oxygen saturation levels if ordered and contact the physician if clarification was needed. This oversight in documentation and monitoring led to a deficiency in providing safe and appropriate respiratory care for the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 25% error rate during the observation of medication administration. This was identified through observations, record reviews, and interviews. Specifically, two residents were involved in the errors. For one resident, a registered nurse administered Lactulose from another resident's supply due to unavailability, and dispensed a higher dose of Biotin than prescribed. For another resident, the nurse failed to administer Lactulose, Furosemide, Oyster Shell Calcium, and Vitamin B12 due to unavailability, and administered incorrect eye drops. Additionally, the nurse did not obtain or document vital signs before administering Metoprolol Succinate ER, as required by the physician's order. The Director of Nursing confirmed that there were no blood pressures recorded for the resident's Metoprolol administration. The facility's policy requires vital signs to be obtained and recorded when applicable, and medications to be administered within a specific time frame, which was not adhered to in these cases. The facility's policies on medication administration and liberalized schedules were not followed, leading to the errors. The policies state that medications should be administered by licensed nurses as ordered by the physician, and any unavailability of medication should be communicated to the attending physician. However, the physician was not notified of the late medications or the unavailability of Lactulose for one of the residents, contributing to the deficiency.
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Illustrative
What surveyors actually found near you
We read the 391 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tampa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northdale Rehabilitation Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Pruitthealth-north Tampa, Llc | 2.9 mi | ★★★★★ | 1 | 0 |
| Tampa Lakes Health And Rehabilitation Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Luxe At Lutz Rehabilitation Center (the) | 3.2 mi | ★★★★★ | 1 | 0 |
| Aviata At Fletcher | 3.7 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.