Above 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 Augustine Home For The Aged during CMS and state inspections, most recent first.
A resident alleged physical abuse by a CNA, resulting in a visible injury. Despite the CNA's claims of racial slurs, the resident's consistent account and the facility's investigation led to the CNA's termination for not following the policy of caring for the resident in pairs.
A resident was admitted to the facility without a documented code status, despite having significant medical conditions. The POST form was incomplete, and staff interviews revealed that the code status should have been documented within 24 hours of admission. The DON confirmed the absence of documentation, and the SSD did not initiate the code status process as required by facility policy.
The facility failed to assess and treat a resident for constipation, did not monitor a resident with congestive heart failure for weight gain, and neglected to follow a physician's order for weight monitoring in another resident. These deficiencies were due to a lack of documentation, failure to follow protocols, and inadequate communication with physicians.
A facility failed to monitor urinary output as ordered for a resident with an indwelling catheter. The resident, with conditions including cerebral ischemia and heart failure, had a care plan requiring urinary output documentation every shift. However, records for August 2024 showed missing documentation on several shifts. An RN confirmed the requirement to document output, which was not followed, contrary to the facility's policy.
The facility failed to date oxygen tubing for three residents receiving respiratory care. Observations showed that the oxygen lines for these residents, who had conditions like chronic respiratory failure and COPD, lacked dates indicating when the tubing was changed. Despite physician's orders and care plans specifying regular changes, the Director of Nursing confirmed the tubing should be changed weekly and dated, which was not followed according to facility policy.
The facility failed to monitor antibiotic use for a resident prescribed Keflex, lacking the use of standardized tools to assess the prescription's appropriateness. The DON indicated that while the physician tracked antibiotics, there was no active surveillance using the McGeer criteria or specific protocols. Facility policies outlined roles for monitoring antibiotic use, but these were not followed, as shown by the absence of documentation and surveillance.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by a Certified Nursing Assistant (CNA). The incident involved Resident B, who alleged that CNA 1 physically assaulted him. On the morning of the incident, Resident B reported that CNA 1 had knocked him out, and later that day, a discoloration and raised area appeared on his forehead. Staff interviews confirmed that this injury was not present during the previous shift, supporting the resident's account of the incident. Multiple staff members provided statements regarding the incident. CNA 1 was observed leaving Resident B's room, and later complained that Resident B had used racial slurs against her. Despite these claims, Resident B consistently reported that CNA 1 had hit him, and his account remained unchanged throughout the investigation. The facility's investigation found inconsistencies in the statements of CNA 1 and RN 4, while Resident B's story remained consistent. The facility's policy required that Resident B be cared for in pairs due to known behavioral issues, but CNA 1 did not adhere to this policy. This failure to follow protocol contributed to the incident, as there was no other staff member present to verify CNA 1's actions. The facility's investigation concluded that the abuse allegations against CNA 1 were substantiated, leading to her termination.
Failure to Document Resident's Code Status
Penalty
Summary
The facility failed to ensure that a resident's code status was obtained and accurately documented in the clinical record for a resident reviewed for advanced directives. The resident, who had diagnoses including hypertension, severe protein-calorie malnutrition, hemorrhage from respiratory passages, and anemia, was admitted to the facility without a documented code status. The Long-Term Care Patient Summary indicated that the resident did not have advanced directives, and the Indiana Physician Orders for Scope of Treatment (POST) form was incomplete, with the section for resuscitation preferences left blank. Interviews with facility staff revealed that the resident's code status should have been documented within 24 hours of admission, but this was not done. The Director of Nursing (DON) confirmed the absence of a documented code status and noted that the POST form was from the resident's previous place of residence. The Social Service Director (SSD) had seen the original POST form but did not initiate the code status process upon admission. The facility's policy on advance directives required documentation of such directives upon admission, but this was not followed in the case of the resident.
Failure to Follow Protocols for Constipation and Weight Monitoring
Penalty
Summary
The facility failed to adequately assess and treat a resident for constipation, as evidenced by the case of Resident 12. The resident, diagnosed with chronic respiratory failure with hypoxia, asthma, and constipation, did not have a documented bowel movement for five days, from 8/27/24 to 8/31/24. Despite having a bowel constipation protocol in place, which required action if no bowel movement occurred for more than two days, there was no abdominal assessment or administration of prescribed medications documented. Interviews with staff revealed that the protocol was not followed, and the Director of Nursing confirmed the lack of documentation and assessment. In another instance, the facility did not properly assess a resident with congestive heart failure, Resident 18, for complications or notify the physician of significant weight gain. The resident experienced a weight gain of 5.1 pounds in a 24-hour period, yet there was no assessment of lung sounds, edema, or chest pain, nor was the weight rechecked for accuracy. The physician was not informed of the weight gain, despite orders to report gains of more than three pounds in 24 hours. Interviews indicated that the expected protocol, including respiratory assessment and physician notification, was not followed. Additionally, the facility failed to adhere to a physician's order for Resident 11, who had a significant weight change. The resident's weight increased by 4.8 pounds compared to the previous month, but there was no documentation of consecutive daily weights or notification to the provider as required. The Director of Nursing acknowledged the absence of documentation and emphasized the expectation for staff to follow physician orders. Facility policies regarding weight monitoring and congestive heart failure were not adequately implemented, contributing to these deficiencies.
Failure to Monitor Urinary Output as Ordered
Penalty
Summary
The facility failed to ensure that urinary output was monitored as ordered by the physician for a resident with an indwelling catheter. The resident, who had diagnoses including cerebral ischemia, heart failure, and chronic respiratory failure with hypoxia, had a care plan initiated to monitor and document urinary output due to bladder obstruction and urinary retention. A physician's order required urinary output to be recorded every shift. However, the Medication and Treatment Record for August 2024 showed missing documentation of urinary output on several shifts, specifically the night shift on August 1st, the evening shift on August 18th, the night shift on August 21st, and the day shift on August 27th. During an interview, an RN confirmed that urinary output was supposed to be documented on the Medication Administration Record. The facility's policy on intake and output, revised in January 2024, required output from catheters to be recorded, which was not adhered to in this case.
Failure to Date Oxygen Tubing for Residents
Penalty
Summary
The facility failed to ensure that oxygen tubing was dated for the day it was changed for three residents who were receiving respiratory care. During observations, it was noted that Residents 18, 12, and 10 were using supplemental oxygen at two liters per minute through a nasal cannula, but the oxygen lines did not have a date indicating when the tubing had been changed. This lack of dating was observed during specific times when each resident was in their respective locations, such as a recliner, sitting in their room, or in a high back wheelchair in the dining area. The clinical records for these residents revealed various diagnoses, including chronic respiratory failure with hypoxia, heart failure, asthma, COPD, pulmonary fibrosis, and obstructive sleep apnea. Physician's orders and care plans for these residents indicated the need for supplemental oxygen and specified that the oxygen tubing should be changed and dated regularly. However, during an interview, the Director of Nursing confirmed that the oxygen tubing should be changed weekly and labeled with the date it was changed, which was not adhered to as per the facility's policy.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to adequately monitor the use of antibiotics for a resident, specifically in the case of a resident who was prescribed Keflex, an antibiotic, without the use of standardized tools to assess the appropriateness of the prescription. The resident's clinical record, reviewed on September 17, 2024, included diagnoses such as vitamin D deficiency, hypertension, polyosteoarthritis, and age-related osteoporosis. Despite these conditions, there was no documentation of a surveillance tool being used to evaluate the necessity of the antibiotic prescribed. During an interview, the Director of Nursing (DON) revealed that the facility's physician was responsible for tracking antibiotics, but there was no active surveillance using the McGeer criteria or any specific protocol in place. The facility's current policies, including the Antibiotic Stewardship Program and the Infection Prevention and Control Program, outlined the roles of the infection preventionist and licensed nurses in monitoring antibiotic use. However, these protocols were not followed, as evidenced by the lack of documentation and surveillance for the resident in question.
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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 Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spring Mill Meadows | 0.2 mi | ★★★★★ | 4 | 0 |
| Brickyard Healthcare - Willow Springs Care Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Marquette | 0.5 mi | ★★★★★ | 3 | 0 |
| Harcourt Terrace Nursing And Rehabilitation | 0.7 mi | ★★★★★ | 27 | 0 |
| Hooverwood | 2.5 mi | ★★★★★ | 12 | 1 |
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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.