Columbia, SC

St Andrews Operator, LLC

1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $41,015 in total fines with 14 recent health deficiencies

3514 Sidney Road, Columbia, SC

(803) 798-9715

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

108

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Yad Healthcare

Operator or chain grouping

Approved since

1979-05-23

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

13 facilities

Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.57

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

0.91

Licensed practical nurse staffing · state 1.01 · national 0.87

Aide hours / resident day

2.21

Nurse aide staffing · state 2.22 · national 2.35

Total nurse hours

3.68

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.48

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

3.30

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.44

Weekend registered nurse coverage · state 0.40 · national 0.47

Physical therapist

0.13

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.63

CMS adjusted RN staffing hours

Adjusted total hours

4.09

CMS adjusted total nurse staffing hours

Case-mix index

1.23

Higher values indicate more complex resident acuity

RN turnover

72%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

79%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,707

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

28.98

Composite VBP score used to determine payment impact.

Payment multiplier

0.9852

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

3.86

Baseline 8.29% · Performance 6.85% · Measure score 3.86 · Achievement 3.29 · Improvement 3.86

Total nurse turnover

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Adjusted total nurse staffing

1.93

Baseline 4.39 hours · Performance 3.63 hours · Measure score 1.93 · Achievement 1.93 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.45%	10.72% 0.3 pts better	No Different than the National Rate · Eligible stays 53 · Observed rate 11.32% · Lower 95% interval 6.45%
Discharge to community	39.1%	50.57% 11.5 pts worse	No Different than the National Rate · Eligible stays 54 · Observed rate 24.07% · Lower 95% interval 26.11%
Medicare spending per beneficiary	0.96	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 42 · Denominator 42
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 42
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	14.29%	2.29% 12 pts worse	Numerator 6 · Denominator 42 · Adjusted rate 12.77%
Healthcare-associated infections requiring hospitalization	6.85%	7.12% 0.3 pts better	No Different than the National Rate · Eligible stays 28 · Observed rate 7.14% · Lower 95% interval 3.5%
Staff COVID-19 vaccination coverage	2.67%	8.2% 5.5 pts worse	Numerator 2 · Denominator 75
Staff flu vaccination coverage	19.23%	42% 22.8 pts worse	Numerator 15 · Denominator 78
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 21 · Denominator 21
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	52%	25.2% 26.8 pts better	Numerator 13 · Denominator 25

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.1	2.0 1.1 pts worse	1.9 1.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.5 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.5	1.9 1.6 pts worse	1.8 1.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.3 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	56.1%	90.5% 34.4 pts worse	93.4% 37.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 91.0% · Q2 50.6% · Q3 32.9% · Q4 50.0% · 4Q avg 56.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	74.4%	90.6% 16.2 pts worse	95.5% 21.1 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 74.4%
Percentage of long-stay residents experiencing one or more falls with major injury	1.6%	3.0% 1.4 pts better	3.3% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 3.9% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.4%	2.9% 1.5 pts better	11.4% 10 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 1.4% · Q4 2.9% · 4Q avg 1.4%
Percentage of long-stay residents who lose too much weight	15.0%	6.2% 8.8 pts worse	5.4% 9.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 21.4% · Q3 17.4% · Q4 11.7% · 4Q avg 15.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.0%	20.4% 5.4 pts better	19.6% 4.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 17.6% · Q3 14.1% · Q4 12.5% · 4Q avg 15.0%
Percentage of long-stay residents who received an antipsychotic medication	16.0%	16.3% 0.3 pts better	16.7% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 12.5% · Q3 21.3% · Q4 22.0% · 4Q avg 16.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	17.9%	14.9% 3 pts worse	16.3% 1.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 46.4% · Q2 0.0% · Q3 6.9% · Q4 19.0% · 4Q avg 17.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	16.5%	12.4% 4.1 pts worse	14.9% 1.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.3% · Q2 10.0% · Q3 7.4% · Q4 18.0% · 4Q avg 16.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.2%	0.7% 0.5 pts better	1.0% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.0%	1.6% 0.4 pts worse	1.7% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 2.6% · Q4 2.8% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	15.0%	17.2% 2.2 pts better	19.8% 4.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 4.0% · Q3 12.6% · Q4 33.4% · 4Q avg 15.0%
Percentage of long-stay residents with pressure ulcers	11.3%	5.8% 5.5 pts worse	5.1% 6.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 14.5% · Q3 12.6% · Q4 9.2% · 4Q avg 11.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	27.5%	79.8% 52.3 pts worse	81.7% 54.2 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 41.5% · Q2 21.8% · Q3 16.1% · Q4 31.0% · 4Q avg 27.5%
Percentage of short-stay residents who had an outpatient emergency department visit	16.7%	14.1% 2.6 pts worse	12.0% 4.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 18.9% · Expected 12.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	4.7%	1.6% 3.1 pts worse	1.6% 3.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q2 4.5% · Q3 3.8% · Q4 9.5% · 4Q avg 4.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	16.4%	78.0% 61.6 pts worse	79.7% 63.3 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 16.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	29.2%	24.7% 4.5 pts worse	23.9% 5.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 29.2% · Observed 37.7% · Expected 30.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-17 · Fire 2025-07-17

14 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-01-24 · Fire 2024-01-24

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2021-10-28 · Fire 2021-10-28

19 health deficiencies

Top issue: Pharmacy Service (5 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-01-24

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-02-09

D · Potential for more than minimal harm 2021-10-28

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-12-03

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-07-17

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-09-19

F · Potential for more than minimal harm 2025-07-17

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2025-09-19

F · Potential for more than minimal harm 2025-07-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-15

E · Potential for more than minimal harm 2025-07-17

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-09-19

D · Potential for more than minimal harm 2025-07-17

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-08-15

D · Potential for more than minimal harm 2025-07-17

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2025-09-19

D · Potential for more than minimal harm 2025-07-17

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2025-09-19

D · Potential for more than minimal harm 2025-07-17

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-08-15

J · Immediate jeopardy 2025-04-29

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-05-30

J · Immediate jeopardy 2025-04-29

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-05-30

F · Potential for more than minimal harm 2025-04-29

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-05-30

E · Potential for more than minimal harm 2025-04-29

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-05-30

D · Potential for more than minimal harm 2025-04-29

F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected 2025-05-30

D · Potential for more than minimal harm 2025-04-29

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2025-05-30

E · Potential for more than minimal harm 2024-01-24

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-02-16

D · Potential for more than minimal harm 2024-01-24

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-02-16

D · Potential for more than minimal harm 2024-01-24

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-02-16

D · Potential for more than minimal harm 2024-01-24

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-02-16

D · Potential for more than minimal harm 2024-01-24

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2024-02-16

D · Potential for more than minimal harm 2024-01-24

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-02-16

D · Potential for more than minimal harm 2024-01-24

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-02-16

D · Potential for more than minimal harm 2024-01-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-02-16

D · Potential for more than minimal harm 2023-07-12

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-08-15

D · Potential for more than minimal harm 2023-04-28

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-05-26

J · Immediate jeopardy 2021-10-28

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2021-06-30

J · Immediate jeopardy 2021-10-28

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2021-06-30

F · Potential for more than minimal harm 2021-10-28

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2022-01-11

D · Potential for more than minimal harm 2021-10-28

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2021-12-17

D · Potential for more than minimal harm 2021-10-28

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2021-12-17

D · Potential for more than minimal harm 2021-10-28

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2021-12-17

D · Potential for more than minimal harm 2021-10-28

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2021-12-17

D · Potential for more than minimal harm 2021-10-28

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2021-12-17

D · Potential for more than minimal harm 2021-10-28

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2021-12-17

D · Potential for more than minimal harm 2021-10-28

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2021-12-17

D · Potential for more than minimal harm 2021-10-28

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2022-01-11

D · Potential for more than minimal harm 2021-10-28

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2021-12-17

D · Potential for more than minimal harm 2021-10-28

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2021-12-17

D · Potential for more than minimal harm 2021-10-28

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2021-12-17

D · Potential for more than minimal harm 2021-10-28

F761 · Pharmacy Service Deficiencies

Health

Corrected 2022-01-11

D · Potential for more than minimal harm 2021-10-28

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2021-12-17

D · Potential for more than minimal harm 2021-10-28