Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Operator, Llc during CMS and state inspections, most recent first.
Surveyors found that the facility did not ensure proper storage, labeling, dating, and discarding of food items in the kitchen, with multiple opened and unsealed food items lacking required dates and labels, some stored on the floor or past expiration, and spoiled produce present. Despite facility policies and staff expectations for food safety, these deficiencies were observed during kitchen inspections.
The QAPI committee did not implement or sustain effective corrective actions for previously identified deficiencies, resulting in ongoing failures to label and date tube feeding bags, opened medications, and food items. These issues were observed again during follow-up, affecting all residents, despite the committee's belief that their audits were effective.
The facility did not maintain required infection surveillance documentation for 2024 and early 2025, as infection control records were missing after the previous ADON/infection preventionist left and took the data. As a result, there was no evidence of systematic infection tracking or reporting for that period, despite ongoing clinical meetings and antibiotic reviews.
Surveyors found expired and discontinued medications, as well as opened medications lacking required labeling, on multiple medication carts. An LPN confirmed the presence of an expired tube feeding formula, an opened insulin pen without an open or expiration date, and a loose unidentified pill. Additional expired and discontinued medications were found on other carts, with staff unsure of proper disposal procedures. The DON stated that nurses are responsible for disposing of such medications and that Unit Managers should audit carts weekly, but these procedures were not consistently followed.
A resident was readmitted with a sacral pressure ulcer that was not consistently documented in skin assessments or the MDS, despite being noted in initial assessments and provider communications. Nursing staff, without a dedicated wound care nurse, failed to accurately record the wound's presence, leading to incomplete and inaccurate documentation of the resident's condition.
A resident with multiple medical conditions, including a history of stroke, hyperglycemia, aphasia, and gastrostomy, was admitted with pressure and non-pressure areas but did not have a baseline care plan developed within 48 hours as required. The care plan was completed weeks later and failed to include the resident's tube feeding needs, as confirmed by the MDS Coordinator.
A resident with a gastrostomy and dysphagia did not receive the physician-ordered tube feed rate, as the feed was administered at 45 mL/hr instead of 50 mL/hr, and the feeding bag was not labeled or dated. Staff interviews revealed that the LPN did not verify the correct rate during shift change, contrary to facility policy requiring verification of tube feed orders.
A resident did not receive safe and appropriate respiratory care when needed, as required by facility protocols.
A cognitively impaired male with a history of behavioral disturbances repeatedly entered female residents' rooms and was found in the room of a non-verbal, dependent female, with reports of inappropriate touching. Despite prior documentation of unsafe behaviors and multiple staff and resident reports, the facility did not implement timely interventions or notify responsible parties, resulting in a failure to protect a vulnerable resident from non-consensual sexual contact.
A facility failed to promptly report and investigate an allegation of potential non-consensual sexual abuse involving two residents. Despite staff and resident reports of inappropriate behavior, management did not notify authorities, the resident's representative, or the Ombudsman in a timely manner. Documentation and interviews revealed incomplete assessments and a lack of thorough investigation, with staff being directed to follow administrative instructions rather than escalate the incident.
Water temperatures in several resident rooms and a shower room were found to be above the facility's policy limit of 120°F, with readings as high as 132°F. The Plant Operations Director increased water temperatures during the winter and did not reduce them after installing water boosters, resulting in excessively hot water. Staff noted the hot water, but no formal complaints were made by residents. The Facility Administrator was unaware of the temperature monitoring process, and the mixing valve was set above the facility's threshold, placing residents at risk for scalding.
Three cognitively intact residents were not treated with dignity or provided a sense of safety after reporting or witnessing a potential non-consensual sexual encounter involving a vulnerable resident. Despite facility policy requiring respect for resident well-being and privacy, staff failed to notify law enforcement or the responsible representative, did not send the affected resident for evaluation, and did not address ongoing concerns of retaliation and insecurity among residents.
A resident with severe cognitive impairment and behavioral disturbances was prescribed Depakote and later Seroquel for behavioral management, but the facility did not implement required monitoring for psychotropic medication use as outlined in its policy. This resulted in a lack of documented oversight for adverse effects and medication effectiveness during the period after Depakote was started.
The facility failed to follow its abuse prevention and investigation policies after two residents were involved in an alleged sexual abuse incident. Staff observed a male resident repeatedly entering female residents' rooms without consent, but the facility did not conduct a thorough investigation, notify law enforcement, or assess all potentially affected residents. Leadership did not interview other residents for safety concerns or implement additional interventions, resulting in inadequate protection and support for those involved.
Failure to Properly Store, Label, and Discard Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage, labeling, dating, and discarding of food items in the kitchen, including the freezer, refrigerator, and dry storage areas. During multiple observations, opened food items were found without open dates or use-by dates, and some were not properly sealed. Specific findings included boxes stored on the floor, opened bags and containers of food without required labeling, and food items past their manufacturer expiration dates. Additionally, some cans were covered with a white powdery substance, and rusted shelves were noted in the walk-in cooler. Perishable items such as cut onions and baby spinach were improperly labeled or visibly spoiled, and several containers of seasonings and other dry goods lacked open or use-by dates. Interviews with the Dietary Manager and Administrator confirmed that the facility's policy requires all food items to be labeled with the name, date of preparation or opening, and a use-by date, and that items past their expiration or use-by date should be discarded. The Dietary Manager stated that daily rounds are conducted in the kitchen, and the Administrator indicated that walkthroughs are performed weekly or monthly. Despite these stated expectations and policies, the observed deficiencies in food storage and labeling practices were not addressed, resulting in noncompliance with professional standards for food safety.
QAPI Committee Failed to Sustain Corrective Actions for Labeling and Storage Deficiencies
Penalty
Summary
The facility's QAPI committee failed to implement effective corrective actions to address previously identified deficiencies, as evidenced by ongoing issues with labeling and dating of tube feeding bags, medications, and food items. During a recertification and complaint survey, the facility was cited for not labeling and dating a tube feeding bag, not labeling opened medications, and not ensuring food was sealed, labeled, and dated with a use-by date. These deficiencies were observed again during follow-up, including an unlabeled tube feeding bag for a resident, opened vials of insulin on two medication carts without opened dates, and unsealed, unlabeled food items in the kitchen. Review of the facility's QAPI meeting minutes showed that while the committee discussed the plan of correction and audit tools, the only documentation was a copy of the CMS-2567 attached to the minutes. During an interview, the Administrator stated that the committee believed the audits were effective, but was unable to explain the continued presence of the same deficiencies. The lack of effective follow-through and sustained corrective action by the QAPI committee contributed to the ongoing noncompliance affecting all residents in the facility.
Failure to Maintain Infection Surveillance and Documentation
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program as required. Specifically, there was no documentation of a surveillance plan for tracking or monitoring infections, communicable diseases, and outbreaks among residents and staff for the entire year of 2024 and the months of January and February 2025. The facility's policy required routine monitoring and surveillance, including the use of standardized assessment tools and regular reporting to the QAPI committee. However, interviews revealed that the infection preventionist identified infections based on resident symptoms and physician input, but there was no evidence of systematic infection tracking or trending prior to April 2025. Further investigation found that the previous Assistant Director of Nursing, who also served as the infection preventionist, left the facility in March 2025 and took the infection control records with her. As a result, the facility was unable to produce any infection control data for the period before April 2025, despite attempts to retrieve the information. While clinical meetings and antibiotic reviews were conducted, and infection numbers were presented in QAPI meetings after April 2025, there was a lack of documented infection surveillance and reporting for the earlier period, constituting noncompliance with infection control requirements.
Failure to Remove Expired and Discontinued Medications and Properly Label Opened Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly labeled, stored, and removed when expired or discontinued, as required by policy and professional standards. During observations of three medication carts, surveyors found an expired box of Nutren 2.0 tube feeding formula, an opened Novolog FlexPen injector without an open or expiration date, and an unidentified loose white pill. Additionally, opened bottles of Sorbitol 70% solution and Robitussin DM were found to be expired and had been previously discontinued. Nursing staff confirmed these findings and acknowledged that the required labeling and removal procedures had not been followed. Interviews revealed that nursing staff were either unaware of or did not follow proper procedures for labeling opened medications and disposing of expired or discontinued drugs. The DON stated that all nurses have the authority to dispose of such medications using a Drug Buster, which is available on each cart, and that Unit Managers are responsible for weekly audits to ensure expired medications are removed. However, the presence of expired, discontinued, and improperly labeled medications on multiple carts indicated a failure to consistently implement these procedures.
Failure to Accurately Document Pressure Ulcer on Assessment and MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the status of a pressure ulcer for one resident. Upon readmission, the resident returned with a sacral pressure ulcer, which was noted in the initial head-to-toe skin check and provider communication log. However, subsequent weekly skin assessments failed to document the presence of the wound, and the Minimum Data Set (MDS) assessment did not indicate the existence of a pressure ulcer, despite physician orders for wound care being in place. The MDS Coordinator relied on nursing documentation, which incorrectly showed the resident's skin as intact during the lookback period, leading to inaccurate reporting on the MDS. Interviews revealed that the facility did not have a dedicated wound care nurse, and wound care responsibilities were shared among nursing staff, with oversight from a wound care provider and nurse practitioner during weekly rounds. The Director of Nursing stated that unit managers are responsible for admission assessments, while floor nurses are expected to document ongoing skin issues. The deficiency resulted from incomplete and inaccurate documentation of the resident's pressure ulcer status in both the skin assessments and the MDS, despite clear evidence of the wound in other records.
Failure to Timely Develop Baseline Care Plan After Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident, as required by its own policy. The resident was admitted with a medical history including cerebral infarction, hyperglycemia, aphasia, and gastrostomy status, and presented with pressure areas on several parts of the body and non-pressure areas on the back and left ear. The baseline care plan was not completed until several weeks after admission and did not address the resident's need for tube feeding. The MDS Coordinator confirmed that the baseline care plan was delayed and incomplete, omitting necessary interventions for the resident's care during the initial period after admission.
Failure to Administer Ordered Tube Feed Rate and Label Feeding Bag
Penalty
Summary
The facility failed to ensure that a resident receiving continuous tube feeding was administered the correct ordered amount and rate of tube feed, as well as failed to properly label and date the tube feed bag. Specifically, the resident, who had diagnoses including gastrostomy status, dysphagia, and adult failure to thrive, was observed to have their tube feed infusing at 45 mL/hr instead of the physician-ordered rate of 50 mL/hr. The facility's policy required verification of the enteral nutrition label against the order before administration, including documentation of the date, time, and initials on the formula label, but this was not followed. During multiple observations, the tube feed was found running at the incorrect rate and without a label or date. Interviews with staff revealed that the LPN did not verify the correct rate with the off-going nurse during shift change, and the Director of Nursing confirmed that both off-going and incoming nurses are required to check tube feed orders during shift changes. The resident's medical record and nutrition notes confirmed the prescribed feeding regimen, which was not adhered to during the observed period.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, but does not provide further details about the specific actions or inactions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
A cognitively impaired male resident with a history of frontal lobe and executive function deficit, impulse disorder, and dementia with behavioral disturbances was documented to have repeatedly entered the rooms of female residents without consent. Despite prior documentation of his inappropriate and unsafe behaviors, including wandering, entering female residents' rooms, and being redirected multiple times, the facility did not implement timely or adequate interventions to prevent further incidents. On one occasion, the resident was found in the room of a non-interviewable, vegetative female resident, with staff and other residents reporting that he touched her inappropriately. Multiple staff and residents reported previous similar incidents, and concerns were raised about the lack of effective action to prevent recurrence. The female resident involved was in a vegetative state, fully dependent on staff for all activities of daily living, and unable to protect herself or report abuse. There was no documentation in her medical record related to the incident, and a required head-to-toe skin check assessment was left incomplete. The resident's representative was not informed of the incident by facility staff and only learned of it from another resident. Staff interviews revealed that some were instructed by administration to alter documentation to downplay the incident, and law enforcement was not notified. The male resident was sent to the hospital for evaluation but returned the same day and was placed back in proximity to the female resident. Multiple interviews with staff and residents confirmed that the male resident's behaviors were known and had been reported prior to the incident, but interventions such as room changes or increased supervision were not implemented in a timely manner. Staff expressed concerns that the facility did not take appropriate steps to protect vulnerable residents, failed to notify responsible parties, and did not follow abuse reporting protocols. The facility's inaction and lack of adequate interventions resulted in a failure to protect the female resident from a non-consensual sexual encounter.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of potential non-consensual sexual abuse involving two residents to the proper authorities and state agency within the required timeframes. According to the facility's own policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury. In this case, a resident was observed entering another resident's room without consent, and there were reports from both staff and other residents of similar behavior. Despite these observations and reports, management was only notified for a possible room change, and there was no immediate notification to authorities or the resident's representative. Documentation in the electronic medical record showed that the resident who entered the room had a history of altered mental status and was redirected multiple times from female residents' rooms. Staff, including an LPN, reported concerns about the resident's sexually inappropriate behavior to the Administrator and DON, but were instructed to follow administrative directives rather than escalate the matter to law enforcement or ensure a thorough evaluation of the potentially affected resident. The resident's representative was not formally notified of the incident, and the facility did not complete a timely or thorough investigation, as evidenced by incomplete documentation of a head-to-toe skin check and lack of interviews with other potentially affected residents. Interviews with staff and the resident's representative revealed that law enforcement and the Ombudsman were not notified promptly, and the Medical Director was also not informed of the potential abuse. The facility administration failed to ensure that all required parties were notified, did not conduct comprehensive resident interviews or assessments to rule out further harm, and did not document or communicate the incident as required by policy and regulation. The deficiency was identified as Immediate Jeopardy due to the failure to report and investigate the allegation of sexual abuse in a timely and appropriate manner.
Unsafe Water Temperatures Exceeding Policy Limits
Penalty
Summary
The facility failed to maintain water temperatures within safe limits, as required by its own policy and federal guidelines, which state that tap water should not exceed 120°F to prevent scalding. During observations, water temperatures in multiple resident rooms and a shower room were found to be significantly above this threshold, with readings ranging from 122.1°F to 132°F. The Plant Operations Director (POD) acknowledged that the water was excessively hot and admitted to increasing the temperature during the winter in response to resident complaints about cold water. However, the temperatures were not reduced after the installation of water boosters, nor were they adjusted back to safe levels until after the surveyor's findings. Interviews with staff revealed that no formal resident complaints about hot water had been made, but an LPN noted that the sinks became very hot during handwashing. The Facility Administrator (FA) was unaware of the specific process used by the POD to check water temperatures and confirmed that the mixing valve had been set above the facility's threshold. The facility's failure to monitor and maintain water temperatures within the safe range placed residents at risk for scalding injuries in all three halls reviewed.
Failure to Maintain Resident Dignity and Safety After Reported Sexual Incident
Penalty
Summary
The facility failed to ensure that three cognitively intact residents were treated with dignity and maintained a sense of safety after reporting or witnessing a potential non-consensual sexual encounter involving a non-interviewable resident. The facility's policy requires that residents be cared for in a manner that promotes their well-being, self-worth, and respect for their private space, but this was not upheld. Multiple residents reported that a resident with a history of wandering and inappropriate behavior entered another resident's room, closed the door, and was found in a potentially sexually inappropriate situation. Staff were observed yelling at the resident to leave the room and calling for assistance, but there was no evidence that law enforcement or the responsible representative was notified, and the affected resident was not sent for evaluation. Residents who witnessed or reported the incident described feeling unsafe and expressed concerns about retaliation from staff. One resident reported being told by staff not to "spread false rumors" and to "shut my mouth," leading to fear about future care. Another resident, who was the roommate of the resident involved in the incident, stated that he avoided his room due to discomfort and observed staff being retaliative. This resident also described the resident in question bragging about the incident to others, with staff present but not intervening appropriately. A third resident reported that the same resident had previously attempted to enter her room and had entered the room of the vulnerable resident on multiple occasions, including at night. She stated that her reports to nursing staff were dismissed and that she did not feel safe, as the resident remained on the same hall and close to the affected resident. The lack of appropriate response to these reports and the ongoing proximity of the resident in question contributed to a continued sense of insecurity and lack of dignity among the residents involved.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure appropriate monitoring for the use of psychotropic medications for a resident with severe cognitive impairment and behavioral disturbances. The resident, who had diagnoses including dementia with behaviors, impulse disorder, and psychoactive substance dependence in remission, was prescribed Depakote and later Seroquel to manage behavioral symptoms. Despite facility policy requiring monitoring for efficacy and adverse consequences when psychotropic medications are used, there was no documented antipsychotic monitoring for the resident after Depakote was initiated. The care plan indicated that monitoring, including observation for side effects and the use of the Abnormal Involuntary Movement Scale (AIMS), should be conducted, but this was not implemented as required. Interviews with the consultant pharmacist, psychiatric nurse practitioner, and medical director confirmed that behavior and antipsychotic monitoring should have been in place when the resident began receiving Depakote. The lack of monitoring persisted until after Seroquel was started, leaving a gap in oversight for potential adverse effects and effectiveness of the psychotropic medication. This failure to follow established protocols for psychotropic medication management led to the identified deficiency.
Failure to Implement Abuse Prevention and Investigation Policies
Penalty
Summary
The facility failed to implement its abuse prevention and investigation policies in response to allegations of sexual abuse involving two residents. According to the facility's own policies, the administrator is responsible for ensuring prevention of further abuse, and investigators are required to interview all relevant staff, residents, and witnesses, as well as review all events leading up to the alleged incident. However, the facility did not conduct a thorough investigation, did not report the incident to law enforcement, and did not ensure that all potentially affected residents were interviewed or assessed. Documentation shows that a male resident repeatedly entered female residents' rooms without consent, and staff observed and redirected him on multiple occasions, but no comprehensive investigation or protective measures were implemented as required by policy. Nursing notes and staff interviews revealed that the male resident was seen entering a female resident's room while a CNA was providing care, and another female resident reported similar behavior the previous night. Staff educated the male resident about not entering other residents' rooms, but there was no documentation of assessment or follow-up for the female resident involved in the incident. Multiple staff members, including CNAs and LPNs, reported the male resident's inappropriate behavior and expressed concerns about the lack of action taken by facility leadership. The facility did not notify the resident representative, did not interview other potentially affected residents, and did not implement additional interventions after repeated incidents. Interviews with facility leadership, including the unit manager, assistant director of nursing, and facility administrator, confirmed that no residents were interviewed regarding safety concerns after the incident, and there was no clear plan to ensure resident safety. The administrator was unaware of the documented behavioral concerns prior to the incident, and staff reported being instructed not to contact law enforcement or send the female resident for evaluation. The facility's failure to follow its own abuse prevention and investigation policies resulted in a lack of protection and support for residents involved in or potentially affected by the alleged abuse.
What surveyors are citing around you — mapped
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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 47 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Columbia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Presbyterian Home Of South Carolina-columbia | 2.1 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare - Lexington | 3.2 mi | ★★★★★ | 1 | 0 |
| Millennium Post Acute Rehabilitation | 3.7 mi | ★★★★★ | 9 | 0 |
| Opus Post Acute Rehabilitation | 4.4 mi | ★★★★★ | 1 | 0 |
| Retreat At Wellmore Of Lexington | 6.1 mi | ★★★★★ | 0 | 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.