Above 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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Augustine Manor during CMS and state inspections, most recent first.
A resident with multiple comorbidities and limited mobility was admitted without a vision care plan, and initial MDS documentation indicated no use of visual appliances. Later, an eye care note and a quarterly MDS documented that the resident wore contact lenses and had bifocals, but the care plan was never updated to address vision needs or management of visual appliances. The resident developed left eye redness and drainage, was diagnosed with conjunctivitis, and started on antibiotic eye drops, yet nursing notes over the next several days did not document ongoing eye assessments or monitoring, even as pain medication was administered without specifying the pain location. When the eye became markedly red with copious purulent drainage and a contact lens was seen but not removed by an RN, an NP ordered ED transfer; however, after an aide removed the lens and the resident declined transfer, there was no documented licensed nurse reassessment or education about the ED order, and no further eye assessments were charted until the resident later reported increased pain, persistent drainage, and vision loss. Only then was the NP contacted and the resident sent to the ED, where she was found to have a corneal ulcer and infection associated with prolonged contact lens wear, ultimately resulting in enucleation of the affected eye, demonstrating a failure to provide appropriate treatment and monitoring according to orders and the facility’s change-of-condition policy.
A resident with recurrent UTIs and multiple comorbidities was ordered nitrofurantoin (Macrobid) 100 mg twice daily for seven days for dysuria due to UTI, with instructions not to start the antibiotic until after a urine specimen was collected. The MAR and progress notes show the first scheduled dose was delayed, several subsequent doses were missed, and the resident ultimately received only 10 of 14 ordered doses, with some doses given before the urine culture was obtained. Attempts to collect urine were delayed or contaminated, and there was no documentation that the NP was notified of the culture delays, early antibiotic administration, or incomplete course of therapy, despite facility policy requiring medications to be administered as ordered.
A resident with a gastrostomy tube, impaired cognition, and dependence for ADLs was care-planned and ordered for Enhanced Barrier Precautions (EBP) due to an indwelling device, with door signage instructing staff to wear gown and gloves for physical contact. During a medication pass, an LPN prepared and administered medications via the resident’s feeding tube without donning any PPE, despite posted EBP signage and existing physician orders. Facility policy on EBP required PPE use for residents with devices such as feeding tubes when performing high-contact care, and the LPN later acknowledged PPE should have been worn.
The facility failed to provide adequate dialysis care for six residents, with deficiencies in pre and post-dialysis assessments and communication with the dialysis center. Incomplete dialysis communication forms and inadequate monitoring of vital signs post-dialysis were observed. Staff interviews revealed a lack of training and understanding of proper dialysis care, contributing to the deficiencies.
The facility failed to maintain dignity for two residents by not covering their urinary drainage bags, which were visible from the hallway. One resident's care plan did not address the use of a privacy bag, and staff interviews revealed a lack of clear instructions in the Kardex. The facility's policy required covers only when residents were out of their rooms, leading to a dignity violation.
A facility failed to ensure a comprehensive care plan and proper documentation for a resident's hand restraint. The resident, with a tracheostomy, had a care plan for bilateral hand mitts but lacked specific monitoring interventions. No restraint orders were documented, and there was no record of restraint application, removal, or family notification. Observations showed the resident wearing a mitt restraint without proper documentation, confirmed by staff interviews.
Failure to Assess and Monitor Eye Condition and Contact Lens Use Leading to Severe Ocular Injury
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, treat, and monitor a resident’s eye and vision needs, including the use of contact lenses, which led to an acute change in condition and hospitalization. The resident was admitted with multiple diagnoses including history of TIA and cerebral infarction without residual deficits, a C2 spinal cord lesion with tetraplegia, systemic lupus erythematosus, major depressive disorder, and type 2 diabetes with neuropathy. On admission, the MDS assessment documented that the resident’s vision was adequate and that she denied using corrective lenses or contacts, and no vision or visual appliance care plan was initiated. Later documentation from an eye care physician noted that the resident wore contact lenses and had new bifocals ordered, and the quarterly MDS documented use of corrective lenses including contacts or glasses, yet the care plan was never updated to address vision needs or the use and management of visual appliances. The resident developed left eye redness and drainage and was diagnosed with conjunctivitis by a nurse practitioner, who ordered antibiotic eye drops. The NP’s note did not specify when symptoms began or include the resident’s input about symptom development. From the time of this diagnosis through several days afterward, nursing progress notes did not document ongoing assessments or monitoring of the left eye, despite the initiation of treatment. During this period, the MAR showed administration of hydrocodone-acetaminophen for pain on multiple occasions without documentation of the pain’s location. According to NIH and CDC information cited in the report, bacterial conjunctivitis treated with antibiotics should show clinical improvement within about 24 hours, and lack of improvement warrants further evaluation; however, there was no documented reassessment or escalation when the resident’s condition did not improve. On a subsequent morning, an RN documented that the resident’s left eye was red, the eyelid was matted shut, and there was copious yellow purulent drainage, with redness extending around the eye and cheek. A contact lens was observed in the left eye, and the RN was unable to remove it despite multiple attempts with sterile saline irrigation and warm compresses. An NP was contacted and ordered transfer to the ED, but before transfer occurred, an aide removed the contact lens. The resident then stated she did not want to go to the ED, the NP was notified, and orders were given to continue conjunctivitis treatment; however, there was no documented licensed nurse assessment of the eye after the contact was removed and no documentation of education regarding the NP’s ED transfer order when the resident refused. From that point until early the next morning, there was no written evidence of eye assessments or monitoring, even though the resident later reported increased left eye pain and continued purulent drainage. Pain medication and warm compresses were provided, but there was no comprehensive assessment or timely notification of the NP or physician until the resident complained of pain and vision loss, at which time she was finally sent to the ED. Hospital records documented a corneal ulcer and infection associated with prolonged contact lens wear, and the resident ultimately underwent enucleation of the affected eye. Additional interviews and record reviews showed that staff were not consistently aware that the resident used contact lenses, despite documentation in the eye care note and quarterly MDS. The DON confirmed there was no vision-related care plan even after bifocals were delivered. The MDS nurse stated that the initial assessment recorded no use of visual appliances based on the resident’s report, and that no care plan was initiated after the quarterly MDS identified corrective lens use. Nursing and therapy staff reported being unaware of contact lens use, and some recalled the resident mentioning eye irritation weeks before the acute episode, with this information only passed informally to an aide. On the morning when the contact lens was reportedly removed, the RN acknowledged not reassessing the eye afterward and leaving at the end of the shift. The on-call NP reported being informed via video call that the contact had been removed and instructed staff to continue eye drops and monitor for changes, but subsequent nursing documentation did not show the required monitoring or timely response to worsening symptoms, culminating in the resident’s transfer to the hospital with severe eye pain, purulent drainage, and vision loss. The report also notes that the facility’s own policy on Notification of Changes required informing the resident, consulting with the physician, and notifying the family or representative when there was a significant change in condition, including deterioration in health or clinical complications. Despite this policy, the record lacked evidence of timely physician/NP notification and comprehensive assessment at several key points when the resident’s eye condition worsened, including increased pain, persistent purulent drainage, and onset of vision loss. A family concern form documented that the resident’s family believed the resident had been in pain for several days, questioned why the NP did not identify the contact lens earlier, and asserted that the nursing process was not followed when the resident reported eye discomfort and was only given pain medication. Collectively, these documented actions and omissions formed the basis for the cited deficiency related to failure to provide appropriate treatment and care according to orders, and to comprehensively assess and monitor the resident’s eye condition and visual appliance use.
Failure to Administer Ordered Antibiotic Regimen for UTI as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an ordered antibiotic for a urinary tract infection (UTI) was administered correctly and consistently according to the prescriber’s orders. The resident involved had a history of transient ischemic attack, cerebral infarction without residual deficits, cervical spinal cord lesion, systemic lupus erythematosus, major depressive disorder, and type 2 diabetes with neuropathy, and was frequently incontinent of bowel and bladder. The care plan identified recurrent UTIs and directed staff to administer antibiotic therapy as ordered, monitor for side effects and effectiveness, and obtain and follow up on lab work. A physician order dated 01/23/26 specified nitrofurantoin (Macrobid) 100 mg by mouth every 12 hours for seven days for dysuria due to UTI, with instructions to document adverse effects, check vital signs with each administration, and document whether symptoms were improving. Progress notes show that on 01/23/26 the resident complained of dysuria and frequency, and the NP ordered Macrobid twice daily and a urine specimen for urinalysis and culture and sensitivity, with instructions not to start the antibiotic until after the urine specimen was collected. The MAR indicated the first scheduled dose on 01/24/26 at 6:00 A.M. was not given, and the first actual dose was administered at 6:00 P.M. that day. No doses were given on 01/25/26, and only the morning dose was given on 01/26/26; the resident then received both scheduled doses on 01/27/26 through 01/30/26. In total, the resident received 10 doses instead of the 14 doses ordered. The antibiotic was also started before the urine culture was obtained, contrary to the NP’s direction. There was no documentation that the NP was notified of the delay in sending the urine culture, the early administration of Macrobid before culture collection, or the missed doses and incomplete course of therapy. Additional documentation shows that attempts to obtain a urine specimen on 01/24/26 and 01/25/26 were unsuccessful due to contamination with stool and delayed transportation related to weather, and there was no evidence the NP was notified of these issues. A straight catheter order was later received, and a urine specimen was finally collected on 01/27/26 and reported on 01/29/26, showing >100,000 CFU/mL of E. coli susceptible to nitrofurantoin. A late entry note indicated the urine culture was positive for E. coli and that the resident received Macrobid with symptom improvement. Subsequent NP documentation on 02/11/26 noted the resident had been treated with a course of Macrobid for UTI but continued to report recurrent UTIs with burning and frequency, and a repeat urinalysis on 02/12/26 showed abnormal findings. In interviews, the ADON confirmed the delays in starting Macrobid, the missed doses, the administration of doses before culture collection, and that the NP was not notified, while the NP stated she was not aware the full seven-day course had not been given and that she had not been contacted to address the incomplete antibiotic course. The facility’s medication policy required medications to be administered consistent with physician orders for dose, strength, route, and frequency.
Failure to Follow Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for one resident. Resident #65 was admitted on 06/08/17 with diagnoses including a gastrostomy (feeding tube), right-sided paraplegia, muscle weakness, and dysphagia, and had impaired cognition per a Minimum Data Set (MDS) assessment. The resident was dependent for toileting, bathing, and transfers. The care plan dated 03/18/26 documented that Resident #65 required EBP related to the presence of a device, with interventions including appropriate signage on the resident’s door and instructions for caregivers to wear disposable gowns and gloves during physical contact with the resident. Current physician orders for March 2026 also specified EBP due to the device every shift. On 03/26/26 at 7:56 A.M., during observation of medication administration, surveyors noted that signs were posted on Resident #65’s door indicating the resident was on EBP and that PPE, including gown and gloves, was required. LPN #320 prepared the resident’s medications, entered the room, and administered the medications via the resident’s feeding tube without donning any PPE. In a subsequent interview, LPN #320 acknowledged that the resident was on EBP due to the feeding tube and stated she should have worn PPE prior to administering the medications. Review of the facility’s policy titled “Enhanced Barrier Precautions,” revised 04/2025, showed that an order for EBP is required for residents with indwelling medical devices such as feeding tubes and that PPE is necessary when performing high-contact care, confirming that the observed practice did not comply with facility policy and physician orders.
Inadequate Dialysis Care and Communication in LTC Facility
Penalty
Summary
The facility failed to provide hemodialysis care and services consistent with professional standards of practice for six residents requiring dialysis. The deficiencies were primarily related to incomplete pre and post-dialysis assessments and a lack of communication between the facility and the dialysis center. For instance, Resident #155's dialysis communication forms were not filled out completely, missing critical information such as post-dialysis vital signs and any complications during treatment. Additionally, the facility's Treatment Administrative Record showed gaps in monitoring the resident's dialysis catheter, with no documentation on certain shifts. Resident #25 also experienced similar issues, with incomplete dialysis communication forms and missing documentation of vital signs monitoring. The Licensed Practical Nurse (LPN) responsible for this resident admitted to not being trained on how to assess dialysis fistulas or grafts, which contributed to the lack of proper monitoring. The Director of Nursing (DON) confirmed the incomplete communication forms and acknowledged the lack of continuity of care between the facility and the dialysis department. Other residents, such as Resident #106, Resident #154, and Resident #114, faced similar issues with incomplete dialysis communication forms and inadequate monitoring of vital signs post-dialysis. The facility's policies and procedures were not followed, as evidenced by the lack of documentation and communication regarding the residents' conditions post-dialysis. Interviews with staff revealed a lack of understanding and training on proper dialysis care, further contributing to the deficiencies observed.
Failure to Maintain Resident Dignity with Uncovered Urinary Drainage Bags
Penalty
Summary
The facility failed to maintain dignity and respect for two residents by not ensuring their urinary drainage bags were covered. Resident #62, who was alert and oriented but dependent on staff for activities of daily living, had a foley bag visible from the hallway, filled with urine, and uncovered. This was confirmed by a Licensed Practical Nurse (LPN), who stated that foley bags were only covered when transported outside of rooms. The facility's policy required urinary drainage bags to be covered, but this was not implemented, violating the resident's right to a dignified existence. Similarly, R448 was observed with an uncovered urinary drainage bag visible from the doorway, exposing the resident's urine. The baseline care plan for R448 did not address the use of a cover or privacy bag for the urinary drainage bag. Interviews with staff, including a State Tested Nursing Assistant (STNA) and an LPN, revealed that while they were aware of the need for privacy, the Kardex did not include instructions for using a privacy bag. The Director of Nursing (DON) confirmed the omission in the Kardex and acknowledged the need for re-education of staff. The facility's policy on the maintenance of urinary catheters required a foley bag cover when residents were out of their rooms but did not address the need for privacy when the bags were visible from the hallway. This oversight led to a failure in protecting the dignity of residents with urinary drainage bags, as observed in the cases of Resident #62 and R448.
Failure to Ensure Proper Restraint Use and Documentation
Penalty
Summary
The facility failed to ensure a comprehensive care plan, physician orders, and interventions for monitoring and evaluation were in place for a resident's hand restraint. The resident, who was admitted with diagnoses including sepsis, dementia, and tracheostomy status, had a care plan that included the use of bilateral hand mitts to prevent decannulation. However, the care plan lacked specific interventions for monitoring and evaluating the restraint use. Additionally, there was no evidence of restraint orders in the resident's active and discontinued orders, and no documentation of when the restraints were applied and removed, or notification to the family about the restraint use. Observations and interviews revealed that the resident was wearing a mitt restraint on the right hand during a surveyor's visit, but the restraint was removed later without documented orders or monitoring. A Licensed Practical Nurse confirmed the resident's history of needing mitt restraints but noted the lack of recent need until the morning of the survey. The Director of Nursing confirmed the absence of documented orders, monitoring, or family notification for the restraint use. The facility's restraint use policy required an order for restraints used for more than six hours, but this was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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Nursing homes near Cleveland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eliza Jennings Home | 0 mi | ★★★★★ | 0 | 0 |
| Algart Health Care | 0 mi | ★★★★★ | 24 | 0 |
| Franklin Plaza Extended Care | 0.7 mi | ★★★★★ | 39 | 0 |
| Cityview Healthcare And Rehabilitation | 3.1 mi | ★★★★★ | 42 | 1 |
| Singleton Health Care Center | 3.9 mi | ★★★★★ | 2 | 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 August 2026) and official state health department websites.