Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Andrews Bay Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that multiple residents did not receive timely ADL, hygiene, and incontinence care, as evidenced by residents lying in bed unshaven, ungroomed, partially unclothed, and in rooms with strong urine odors, as well as reports of long waits for call light responses and assistance with toileting and changing. One resident reported not having a shower since admission and only receiving sponge baths despite preferring showers, while documentation showed another dependent, incontinent resident had not received a bath since admission. Care plans and MDS assessments documented significant ADL assistance needs, incontinence, and mobility and cognitive impairments, yet residents continued to experience delays and unmet care needs. An RN stated CNAs did not make rounds or provide proper care and that staffing was sometimes short, and the DON acknowledged grievances about delayed call light response and care not being provided as expected.
Surveyors found that call lights were frequently not within reach of dependent residents, with devices clipped between beds and dressers, wrapped around wheelchair handles near the floor, hanging on walls or curtains, or lying on the floor while residents were in bed. A call light was observed sounding for an extended period while multiple staff, including a nurse, remained at or near the nurses’ station and walked past the room without responding. Several residents reported long waits after pressing call lights, sometimes over 30–45 minutes, leading them to sit in hallways to obtain help or to remain soiled before staff arrived. Resident council grievances over several months documented repeated concerns about staff on phones in hallways, call lights not being answered promptly, and residents not being changed in a timely manner. The DON acknowledged multiple grievances and stated expectations for care every two hours and call light response within 5–10 minutes but could not provide documentation of formal training on these issues.
A resident was admitted with an old, non-open sacral area and extensive bruising to the abdomen, back, and thigh, but subsequent nursing notes and a weekly skin assessment documented the skin as intact with no wounds. Later, a physician identified unstageable DTI wounds to the right heel and sacrum and ordered daily skin prep and hydrocolloid dressings, and the care plan was revised for skin breakdown risk. The resident was hospitalized for abdominal pain and a psoas hematoma while on anticoagulant therapy, then readmitted with ongoing bruising, an open sacral area, and a DTI to the right heel, again requiring wound care orders and care plan revision. These events show that staff failed to consistently recognize, document, and monitor the resident’s bruising and pressure-related wounds in accordance with the facility’s wound management policy.
A resident receiving long-term Levothyroxine and Abilify did not have required laboratory monitoring for thyroid function or blood glucose, and the consultant pharmacist failed to identify or report these irregularities during monthly medication regimen reviews, contrary to facility policy.
Failure to Provide Timely ADL, Hygiene, and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide activities of daily living (ADL) care, including hygiene and incontinence care, to maintain or improve residents’ abilities and respect their choices. During a tour, surveyors observed one resident lying in bed awake, screaming in pain, wearing only an incontinence brief with no sheets or blankets, unshaven, with unkempt hair, and in a room with a strong urine odor. Another resident was observed in bed with the head of the bed elevated, eyes closed, unshaven, and with unkempt hair. Two additional residents’ rooms had strong urine odors; one resident reported waiting for someone to change her after staff said they would get someone but never returned, and another resident stated she had been waiting to be changed, had pressed her call light, and that it usually took staff more than 30–45 minutes to respond depending on the time of day. Follow-up observations showed that the first resident remained in bed in a hospital gown with facial hair and unkempt hair, and another resident continued to appear unshaven and ungroomed. One resident reported not having had a shower since admission two weeks earlier, stating that he had only received a sponge bath and preferred to get up for a shower. Record reviews showed that a resident with a displaced femur fracture, dementia, PTSD, anxiety, and dependence on staff for all ADLs had not received a bath since admission, despite documentation that he was incontinent of bowel and bladder and had severe cognitive and mobility impairments. Another resident with diabetes, fractures, multiple myeloma, cirrhosis, wheelchair use, and frequent incontinence had a care plan for ADL self-care deficit and incontinence risk, and a further resident with a fibula fracture, UTI, metabolic encephalopathy, and need for personal care required moderate to dependent assistance with ADLs and had a care plan for ADL self-care deficit and incontinence risk. Documentation for the resident with the fibula fracture showed only periodic bed baths and no showers, despite his stated preference for showers. A resident with hypertensive heart disease, history of TIA and cerebral infarction, wheelchair use, maximal assistance needs for ADLs, and constant incontinence had a care plan for decreased ADL ability and a preference not to be awakened at night for incontinence care. Another resident with a CVA, right-sided hemiplegia, COPD, UTI, and hypertensive heart disease, who required partial to maximal assistance with ADLs, reported having to sit at the nurses’ desk waiting for help to use the bathroom, stating that call lights took over 30 minutes and sometimes up to an hour to be answered. An RN reported that CNAs did not make rounds or provide proper care, that she had written up CNAs without seeing changes, and that staffing was sometimes short. The DON acknowledged multiple grievances about delayed call light response and care not being provided timely, stated that care should be done every two hours and as needed and call lights answered within 5–10 minutes, and indicated that while she had spoken to staff, there was no formal, documented training related to these issues. The facility’s incontinence policy stated that residents should receive care and services to promote urinary continence.
Failure to Ensure Accessible Call Lights and Timely Response to Resident Requests
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that the call light system was accessible to dependent residents in their rooms and bathrooms, as required by facility policy. During a tour on 02/23/26, multiple rooms were observed where call lights were not within reach of residents lying in bed. Examples included call lights fastened with clips between the bed and bedside dresser, wrapped around wheelchair handles near the floor, hanging on the wall, clipped to privacy curtains, or lying on the floor at the head or side of the bed, all out of reach of the residents. Photographic evidence was obtained of these call light placements. Additional observations on the 300 hallway showed a call light activated and beeping for an extended period while several staff members sat at the nurses’ station, a nurse stood at the end of the hallway near the medication cart, and multiple staff walked past the room without responding. The call light remained unanswered for at least 15 minutes before the nurse at the end of the hallway acknowledged the light and stated she was trying to finish other tasks before entering the room, explaining that the resident wanted her phone plugged in to charge. On 02/24/26, a follow-up tour again found call lights in several rooms lying on the floor out of reach of residents who were in bed. Resident interviews corroborated these observations. One resident reported pressing the call light and sometimes having no one respond, or staff entering the room, turning off the call light, stating they would return, and then not coming back; this resident described sitting in the hallway or at the nurses’ station to obtain assistance and reported seeing staff on their phones playing games, with call light response times reported as over 30 minutes and sometimes up to an hour. Another resident stated that staff sometimes did not come when the call light was turned on and that, when they did respond, it was too late and the resident had already soiled themselves. A third resident reported waiting to be changed after pressing the call light, stating that response times depended on the time of day and were usually more than 30–45 minutes. Review of resident council grievances over three consecutive months showed repeated complaints about staff being on phones in the hallway, call lights not being answered in a timely manner, and residents not being changed promptly after incontinence episodes. The DON acknowledged multiple grievances regarding delayed call light response and untimely care and described expectations that care be provided every two hours and as needed, and that call lights be answered within 5–10 minutes, but could not provide documentation of formal training related to these issues.
Failure to Monitor and Treat Pressure Ulcers and Bruising Leading to Worsening Wounds
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing monitoring and treatment of pressure-related wounds and bruising for one resident, resulting in worsening wounds and the development of a new pressure ulcer. Upon admission, the resident reported having only an old, non-open sacral wound and no other wounds. An admission skin note documented extensive deep purple bruising to the left abdomen extending to the back shoulder blade, bruising to the right lower abdomen and left thigh from groin to knee, swelling of both arms, and a callous on the bottom of the right foot, while noting the sacral area as an old site that was not open. However, subsequent progress notes over multiple days and a weekly skin evaluation documented the resident’s skin as warm, dry, and intact with no wounds present, despite the earlier findings of extensive bruising and the known old sacral wound. A physician wound care note later documented the presence of an unstageable DTI of the right heel and an unstageable DTI of the sacrum, with corresponding treatment orders for skin prep and hydrocolloid dressings, and the care plan was revised to reflect risk for skin breakdown. The resident subsequently experienced abdominal pain, and hospital records showed admission for abdominal pain and a psoas muscle hematoma while on anticoagulant therapy. After readmission, the resident’s skin issues included a midline to the left upper arm, bruising to the left hip and abdomen, scattered bruising to the right forearm, an open sacral area, and a DTI to the right heel, with new wound care orders and care plan revisions for skin breakdown risk. The facility’s wound management policy states that in the absence of treatment orders the licensed nurse will notify the physician to obtain orders and that treatment effectiveness will be monitored through ongoing assessment, but the documentation and interviews show inconsistent and inadequate monitoring and documentation of the resident’s wounds and bruising, including failure to identify and document the heel wound at admission and failure to consistently monitor the extensive bruising and evolving pressure injuries.
Failure to Identify and Report Medication Monitoring Irregularities
Penalty
Summary
The facility failed to ensure that the consultant pharmacist identified and reported irregularities related to the long-term use of anti-psychotic and thyroid medications for one resident. The resident had been receiving Levothyroxine Sodium for hypothyroidism and Abilify for bipolar disorder over an extended period. Review of the medical record showed there were no current physician's orders for laboratory testing to monitor thyroid function (TSH or free T4) or fasting blood glucose, despite the known need for such monitoring with these medications. The last available laboratory data was from a hospital visit, not from routine facility-ordered monitoring, and showed abnormal glucose levels. Over the past year, monthly medication regimen reviews by the consultant pharmacist did not include any recommendations for necessary laboratory assessments related to the use of Levothyroxine Sodium or Abilify. Interviews with the DON and the consultant pharmacist confirmed the absence of such monitoring and recommendations. The facility's policy requires comprehensive monthly medication reviews, including evaluation of medication response and reporting of findings, but this was not followed in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6 citations issued within 25 miles in the last 12 months — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Panama City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Panama City | 1.4 mi | ★★★★★ | 1 | 0 |
| Community Health And Rehabilitation Center | 3.8 mi | ★★★★★ | 5 | 0 |
| Aviata At Emerald Shores | 4.7 mi | ★★★★★ | 0 | 0 |
| Clifford Chester Sims State Veterans Nursing Home | 5.9 mi | ★★★★★ | 0 | 0 |
| Shores Nursing And Rehab Center | 33.9 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for St Andrews Bay Skilled Nursing And Rehabilitation.
100% money-back within 48 hours.
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.