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 Augustine Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with obesity, lymphedema, seizure history, and an intact BIMS score was care planned for 2-person assistance with bed mobility and had a prior documented fall when care was provided by a single CNA. On a later date, a CNA who normally worked in activities was reassigned to the nursing unit, did not review the care plan, and relied on a brief verbal report that did not mention the 2-person bed mobility requirement. While providing incontinent care alone, the CNA turned the resident toward the window as the resident held the side rail; the resident’s heavy legs slipped off the bed, pulling his body to the floor. Nursing notes and an LPN’s account documented that the resident’s lower body was on the floor in a twisted position while he held the side rail, after which he complained of right hip pain. Imaging confirmed an acute proximal femur fracture, and the facility’s abuse/neglect policy defined neglect to include performing 1-person assistance when 2-person assistance is care planned.
A resident with obesity, lymphedema, prior right hip fracture, and a care plan requiring two-person assistance for bed mobility experienced a fall and new right femur fracture when an Activities Assistant/CNA, unfamiliar with the resident and working alone due to staffing call-outs, turned the resident on his side in bed without reviewing the care plan or providing preparatory instructions. The resident’s legs slipped off the bed, pulling his body to the floor while he held the side rail, and he later complained of hip pain; a STAT x-ray confirmed an acute transverse proximal femur fracture. This occurred despite prior documentation of a similar fall during solo in-bed care and existing policies requiring two-person assistance for turning and positioning and use of person-centered care plans to communicate individualized ADL needs to CNAs.
The facility failed to maintain the kitchen exhaust system in safe operating condition due to an expired inspection date on the kitchen hood. The CDM and Director of Maintenance were unaware of the overdue inspection, as the vendor typically conducted inspections automatically every three months. This oversight was contrary to the facility's policy aimed at preventing workplace hazards.
The facility failed to label medications according to professional principles and allowed expired medications to be used for four residents. An LPN was observed preparing expired insulin, and further inspection revealed additional expired prescriptions. Interviews confirmed lapses in the procedure for removing expired medications, and the facility's policy outlined the need for proper storage and labeling.
The facility failed to follow proper food handling and sanitation practices, as observed during a kitchen tour. Unlabeled and expired food items were found in the walk-in refrigerator and dry storage room, indicating non-compliance with the facility's policies. Interviews with dietary staff revealed inconsistencies in implementing food labeling and expiration management procedures.
The facility failed to maintain a safe, clean, and comfortable environment for residents, with issues such as broken air conditioning, flickering lights, pest infestations, and stained curtains observed in several rooms. Residents reported discomfort and unaddressed maintenance requests, highlighting a lack of coordination between housekeeping and maintenance departments.
The facility failed to provide appropriate ROM treatment for two residents with limited mobility. One resident with left-sided hemiplegia was not receiving assistance with ROM exercises, and another resident with Parkinson's disease and contractures was not receiving the prescribed ROM exercises. Despite care plans and recommendations, there was no documentation or communication among staff regarding the implementation of these programs, leading to inadequate care.
The facility failed to implement a policy for the use and storage of foods in personal refrigerators, resulting in unsanitary conditions. Multiple residents had expired and unlabeled food in their refrigerators, and a live roach was found in one. Staff interviews revealed unclear responsibilities and missing temperature logs. The DON confirmed the absence of a policy and acknowledged the need for improvement.
An LPN failed to perform hand hygiene during medication administration for two residents, contrary to the facility's infection control policy. The LPN did not wash hands before or after handling medications, which was acknowledged during an interview.
Failure to Follow Two-Person Bed Mobility Care Plan Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not ensuring that a CNA followed the resident’s care plan requirements for two-person assistance with bed mobility. The resident had an active care plan, revised on 12/23/25, identifying a potential for falls related to seizure history, a history of placing himself on the floor when upset, and raising his bed to the highest position. Interventions included two-person assistance with bed mobility, floor mats on both sides of the bed, and two-person assistance for transfers. A prior nursing progress note dated 11/3/25 documented that the resident had a witnessed fall when a CNA provided morning care alone, turned the resident on his left side, and he slid out of bed onto the fall mat. On 11/4/25, the IDT met and documented that the resident was to have two aides perform care while in bed. The resident’s medical record showed multiple significant diagnoses, including a displaced intertrochanteric fracture of the right femur (subsequent encounter), peripheral vascular disease, myelodysplastic syndrome, obesity, lymphedema, seizures, major depressive disorder, ADHD, hereditary and idiopathic neuropathy, and rheumatoid arthritis. An annual MDS with ARD 12/09/25 documented a BIMS score of 14/15, indicating intact cognition. Active orders included an air mattress, antidepressant (venlafaxine), gabapentin for neuropathy, Lasix, levetiracetam for seizures, and, following the fall with hip fracture, orders for right hip surgical incision care, morphine for pain, and later a Hoyer lift transfer with two-person assist. These clinical details, combined with obesity and lymphedema, contributed to the need for two-person assistance with bed mobility as reflected in the care plan and staff documentation. On 2/3/26 at approximately 2:00 PM, CNA A, who normally worked as an Activities Assistant and was assigned to the nursing unit that day due to staffing call-outs, entered the resident’s room to provide incontinent care. CNA A reported that she had not reviewed the resident’s care plan at the beginning of the shift because she arrived at 8:00 AM to find that breakfast trays had already been passed and the previous shift staff had left, and she stated she did not have time to review care plans. She said she briefly asked two CNAs for a rundown of her assigned residents, and they did not mention that this resident required two-person assistance for bed mobility. While providing care alone, she turned the resident toward the window while he held the side rail; his large, heavy legs slipped off the bed, and the weight of his lower body pulled him off the bed so that his lower body was on the floor and his upper body remained elevated as he held the rail. Nursing documentation and LPN B’s interview confirmed that the CNA was alone, that the resident was found with his lower body on the floor in a twisted angle while holding the side rail, and that the resident complained of right hip pain after being assisted back to bed with a Hoyer lift and multiple staff. An x-ray showed an acute transverse fracture of the proximal femur, and the resident was sent to the ER and admitted for surgery. The facility’s abuse/neglect policy defined neglect to include performing one-person assistance when a resident is care planned for two persons and identified failure to implement effective communication systems across shifts as potential neglect, which aligned with the circumstances of this incident.
Failure to Provide Required Two-Person Assistance During Bed Mobility Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and staff assistance to prevent an avoidable fall with major injury for a resident who required two-person assistance for bed mobility. The resident had multiple diagnoses, including a prior displaced intertrochanteric fracture of the right femur, obesity, lymphedema, seizures, neuropathy, and other chronic conditions. The resident’s care plan, revised prior to the incident, identified a potential for falls related to seizure history and behaviors, and specifically required two-person assistance with bed mobility and transfers, as well as floor mats on both sides of the bed. The resident’s MDS showed intact cognition, and the record documented that he was dependent on staff for turning, repositioning, and other ADLs. Prior to the February incident, the resident had a documented fall on a previous date when a CNA provided morning care alone, turned the resident onto his side, and he slid from the bed onto a fall mat. Following that fall, the IDT documented that the resident was to have two aides perform care while in bed. Despite this, on the date of the later incident, an Activities Assistant (CNA A) who was covering on the nursing unit due to staffing call-outs provided incontinent care to the resident alone. CNA A reported that she did not have time to review care plans at the start of the shift, that the previous shift staff had already left, and that the two CNAs she briefly consulted did not tell her the resident required two-person assistance for bed mobility. She also stated she was unfamiliar with the resident and that this was her first time working with him. During the incident, CNA A turned the resident on his side in bed toward the window while he was holding the side rail. Because of his large, heavy legs related to lymphedema and obesity, his legs slipped off the side of the bed, pulling his lower body to the floor while his upper body remained partially supported by the side rail. The resident reported that he was not given instructions or preparation before being turned and that the turn happened quickly, after which he found himself on the floor. LPN B, the assigned nurse, found the resident with his lower body on the floor in a twisted angle and his upper body off the floor holding the side rail. The resident was assisted back to bed with a Hoyer lift and multiple staff, after which he complained of right hip pain. A STAT x-ray was ordered and showed an acute transverse fracture of the proximal right femur, and the resident was subsequently sent to the hospital for further evaluation and surgery. The facility’s own turning and positioning policy required use of two persons for the procedure as needed and explanation of the procedure to the resident, and the person-centered care plan policy required that individualized care plan interventions be entered into the electronic record to guide CNAs in meeting residents’ care needs.
Failure to Maintain Kitchen Exhaust System Inspection
Penalty
Summary
The facility failed to ensure that essential kitchen equipment was maintained in safe operating condition, specifically the kitchen exhaust system, which was not inspected to prevent excessive grease build-up. During a kitchen tour, it was observed that the inspection date on the kitchen hood above the cook area was expired. The Certified Dietary Manager (CDM) reported that the exhaust hood was supposed to be inspected every three months, with the Maintenance Department responsible for contacting the vendor. However, the Director of Maintenance was unaware that the inspection was overdue, as the vendor typically came automatically every three months. The CDM also stated that broken equipment was reported to the Maintenance Department, but she was not aware that the exhaust hood inspection was due, as the vendor usually came automatically. A review of the facility's policy and procedure titled Safety Principles indicated the purpose was to prevent injury to food service employees through exposure to workplace hazards.
Medication Labeling and Expiration Deficiency
Penalty
Summary
The facility failed to label drugs and biologicals in accordance with currently accepted professional principles and allowed medications to be used past their expiration date for four residents. During a medication administration observation, an LPN was seen preparing an insulin FlexPen for a resident, which was found to be expired. The LPN acknowledged the expiration but questioned if it was still acceptable to administer. Further inspection of the medication cart revealed additional expired insulin prescriptions for two other residents and one insulin without an opened or expired date. Interviews with the Director of Nursing and the Nurse Manager confirmed that one resident did not have current orders for insulin, although they did in the past. The facility's procedure for removing discontinued or expired medications involved the nurse in charge of the medication cart at the time of discontinuation. Additionally, nurse managers were responsible for weekly checks of the medication carts to remove expired or discontinued medications. The facility's policy outlined general storage procedures, including the requirement to separate expired or contaminated medications from others until they are destroyed or returned.
Improper Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, which are crucial to preventing foodborne illnesses. During a kitchen tour, surveyors observed that several food items in the walk-in refrigerator and dry storage room were not date-marked, including an open box of tomatoes, a bin of potatoes, and an open bag of onions. Additionally, expired food items, such as thickened lemon-flavored water containers, were found in the dry storage room and the south unit nourishment room refrigerator. These observations indicate a lack of compliance with the facility's policy on food labeling and expiration management. Interviews with dietary staff, including a Certified Dietary Manager (CDM) and dietary aides, revealed inconsistencies in the implementation of the facility's food handling policies. Staff members were responsible for stocking the dry storage room, refrigerator, and freezer, and were expected to label and date food items upon receipt and after opening. However, the presence of unlabeled and expired food items suggests a failure to follow these procedures. The facility's policy, which aligns with the FDA Food Code, emphasizes the importance of the First-In-First-Out (FIFO) system and proper date marking to ensure food safety and prevent pathogen exposure.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several environmental concerns observed during a survey. In five resident rooms, issues such as heavily stained privacy and window curtains, holes in window curtains, uncomfortable temperatures, and bug carcasses were noted. One resident reported that the air conditioning in her room had been broken for about a month, causing discomfort due to night sweats, and despite notifying staff, the issue remained unresolved. Another resident experienced a flickering bathroom light that had not been fixed despite multiple requests to maintenance. Additionally, a resident reported pest issues, with a dead roach observed in the bathtub and an overall unkempt room appearance. Further observations included a broken toilet in one resident's room, requiring the resident to use another restroom down the hall. A personal refrigerator in another room was found to have a live roach inside, and the floor in front of it was heavily stained. Interviews with the Housekeeping Supervisor and Director of Maintenance revealed a lack of coordination and responsibility for addressing these issues, with no established policies and procedures to manage the environmental concerns identified during the survey. The Director of Maintenance acknowledged the ongoing issues with the flickering light and the need for further repairs.
Failure to Provide Appropriate ROM Treatment for Residents
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents with limited range of motion (ROM), leading to deficiencies in their care. Resident #29, who has left-sided hemiplegia and other medical conditions, was observed without the necessary splint and reported not receiving assistance with ROM exercises. Despite having a care plan that noted the potential for contractures and the need for a functional maintenance program (FMP), there were no orders or documentation indicating that such a program was in place or being followed. Resident #55, diagnosed with Parkinson's disease and multiple contractures, was also not receiving the prescribed ROM exercises. Although the resident was supposed to be on a restorative nursing program for active ROM and a splint and brace program, there was no documentation of these services being provided. Interviews with staff revealed a lack of communication and documentation regarding the residents' participation in the FMP, with staff unaware of any refusals or discontinuations of the program. The facility's policy on restorative services requires comprehensive reviews and documentation to ensure residents receive necessary rehabilitative services. However, the lack of documentation and communication among staff members led to the failure to implement and monitor the prescribed ROM programs for both residents. This deficiency highlights a gap in the facility's adherence to its own policies and procedures, resulting in inadequate care for residents with limited ROM.
Lack of Policy for Personal Refrigerators Leads to Unsanitary Conditions
Penalty
Summary
The facility failed to develop and implement a policy regarding the use and storage of foods brought to residents by family and other visitors, leading to unsafe and unsanitary conditions. During an initial tour, it was observed that multiple residents had personal refrigerators in their rooms without temperature logs, and expired food was found in several rooms. A live roach was also observed in one of the refrigerators. Interviews with staff revealed that the responsibility for checking these refrigerators was unclear, with overnight nurses supposedly in charge, but no current temperature logs were available. The Director of Nursing confirmed the absence of a policy and acknowledged the lack of structure in monitoring these refrigerators. The deficiency directly impacted residents in four rooms and had the potential to affect all residents with personal refrigerators. The facility did not maintain a list of residents with personal refrigerators, and there was no system in place to ensure the safe storage and handling of food items. The lack of a policy and proper monitoring led to expired and unlabeled food items being stored in residents' refrigerators, posing a risk to their health and safety. The Director of Nursing admitted that there was room for improvement in addressing these concerns.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program during medication administration, as observed in the cases of two residents. During a medication administration observation, an LPN was seen preparing medication for a resident at the nurses' station without performing hand hygiene before handling the medication. After administering the medication, the LPN also failed to perform hand hygiene before proceeding to administer medication to another resident. This was contrary to the facility's policy, which requires staff to perform appropriate hand hygiene before and after direct resident contact. The LPN acknowledged forgetting to perform hand hygiene during an interview conducted shortly after the observation.
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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.
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Nursing homes near Saint Augustine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ponce Therapy Care Center And Rehab, The | 0.7 mi | ★★★★★ | 0 | 0 |
| Lilac At Bayview, The | 1.6 mi | ★★★★★ | 0 | 0 |
| Moultrie Creek Nursing And Rehab Center | 4.3 mi | ★★★★★ | 0 | 0 |
| Clyde E Lassen State Veterans Nursing Home | 10.1 mi | ★★★★★ | 3 | 0 |
| Westminster St Augustine | 11.8 mi | ★★★★★ | 0 | 0 |
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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.