St Augustine Health And Rehabilitation Center

Based on kitchen and nourishment room observations, staff interviews and a review of the facility's policies and procedures, the facility failed to follow proper sanitation and food handling practices to prevent the potential outbreak of foodborne illnesses for residents receiving food services from the facility, by failing to ensure food items were properly labeled and dated, and cleanliness of essential kitchen equipment was maintained in sanitary condition. Unsanitary food handling and storage practices have the potential to affect all residents receiving food services from the facility. The findings include:A tour of the kitchen was conducted on 5/18/2026 at 10:05 AM. During the tour, one open bag of thickener powder was observed in the dry storage room, two open boxes of frozen beef patties were observed in the freezer, and one box of pasteurized eggs was observed in the refrigerator with no labels or date markings. One expired carton of fat-free chocolate milk (dated 5/8/26), two expired cartons of whole milk (dated 5/9/26 and 5/12/26), and nine half empty cartons of whole…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record reviews and a review of the facility's policies and procedures, the facility failed to provide a notice of transfer/discharge and a copy of the actual transfer/discharge form to the Long-Term Care (LTC) Ombudsman's Office for four (Residents #3, #55, #29 and #93) of nine residents reviewed for transfer/discharge. Appropriate notification to the LTC Ombudsman's office provides added protection to residents from being inappropriately transferred or discharged . It provides residents with access to an advocate who can inform them of their options and rights, and it ensures that the LTC Ombudsman's office is aware of facility practices and activities related to transfers and discharges. The findings include:1. A review of Resident #3's medical record revealed an admission date of 2/9/2026 with diagnoses including End-Stage Renal Disease (ESRD). She was transferred to an acute-care hospital on 4/1/2026 and returned to the facility on 4/14/2026. The resident's medical record included no evidence of the facility having notified the LTC Ombudsman's office. There…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, interviews and review of the facility's policies and procedures, the facility failed to ensure that one (Resident #109) of four residents reviewed for impaired skin integrity, received care and treatment in accordance with professional standards of practice. Resident #109's wound dressing was not changed for 24 days. Failure to change a wound dressing for 24 days can result in a bacterial infection, increased pain, additional tissue damage and/or the dressing fusing to healing skin.The findings include:On 5/19/26 at 11:18 a.m., an observation was made of Resident #109 in her room on the Memory Care unit. A dressing was observed on her right lower extremity (RLE) which was dated 4/25/26. Resident #109 was unable to remember what occurred or why she had the dressing on.On 5/20/26 at 11:18 a.m., an observation was made of Resident #109 in her room. The same 4/25/26 dressing was observed on her RLE. (Photographic evidence obtained)A review of the resident's medical record revealed an admission date of 8/19/19 with diagnoses including mild protein…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to ensure essential kitchen equipment was in safe operating condition, by failing to maintain the inspection of the kitchen exhaust system to prevent excessive grease build-up. This could potentially endanger staff, residents and any other building occupants due to the risk for fire. The findings include: A kitchen tour was conducted on 09/11/24 at 11:05 AM. The kitchen hood located above the cook area had an inspection date that was expired. The documented date of inspection should have occurred between 5/2024 and 8/2024. (Photographic evidence obtained) In an interview with the Certified Dietary Manager (CDM) on 09/12/24 at 1:53 PM, she reported that the exhaust hood was inspected every three months, and the Maintenance Department was responsible for contacting the vendor. During an interview with the Director of Maintenance on 09/12/24 at 2:23 PM, he stated he did not notice that the inspection was expired. The vendor came automatically every three months…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to 1) Label drugs and biologicals in accordance with currently accepted professional principles, and 2) Ensure medications were not used past the expiration date for four (Residents #45, #3, #8, and #90) of 35 residents in the total survey sample. Failure to ensure medications are labeled appropriately and are not expired, pose a risk to resident health due to potentially reduced efficacy and contamination. The findings include: During medication administration observation on 09/10/24 at 10:40 AM, Licensed Professional Nurse (LPN) G was observed preparing a Novolog (insulin) FlexPen (a multi-dose injection pen designed to be used multiple times by the same receiver) for Resident #45. She read the label, placed a new needle on top of the FlexPen, primed the needle, set the correct ordered dose to be administered, and provided it for inspection. Reading the label revealed an opened date of 7/19/24 and an expired date of 8/16/24. When LPN G was asked to look at the expired date, she acknowledged that the FlexPen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all residents who consumed foods from the facility's kitchen, by failing to seal and date mark open food products in the walk-in refrigerator, and discard food products on or before the expiration date. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 09/09/24 at 10:14 AM. During the tour, no date markings were observed on one open box of tomatoes, one bin of potatoes, or one open bag of onions in the walk-in refrigerator. The dry storage room had one open bag of wrapped potato chips with no date marking and nine thickened lemon-flavored water containers with expiration dates of 09/02/24. On 09/09/24 at 11:36 AM, the Certified Dietary Manager…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide its residents with a safe, clean, comfortable, and homelike environment, directly affecting residents in five (Rooms 118, 121, 124, 126, and 132) of 66 resident rooms. Failure to maintain a safe, clean comfortable environment could result in accidents, the spread of infection, and a negative impact to residents' psychosocial well-being. The findings include: During an initial tour of the facility on 9/9/2024 from 9:30 AM through 12:00 PM, the following environmental concerns in resident areas were observed: Heavily stained privacy curtains and window curtains, holes in window curtains, uncomfortable temperatures, and bug carcasses in the following resident rooms: Rooms 121, 118, 124, 126, and 132. (Photographic evidence obtained for all) During an interview on 9/9/2024 at 11:36 AM with Resident #9, she stated the air conditioning (AC) in her room had been broken for about a month. She further stated she and her roommate had both notified staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that two residents (#29 and #55) with limited range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. There were three residents reviewed for limited range of motion in a total survey sample of 35 residents. The findings include: 1. During the initial tour on 09/09/24 at 10:00 AM, Resident #29 was observed in her room seated in her wheelchair. She had left-sided weakness. Her left foot was dorsiflexed (upward bending and contracting) and crossed over her right foot. When she was asked if she had any concerns, she used a communication board with alphabet letters on her bedside table and spelled out, It she would like the mess cleaned up. She pointed across the room next to her TV. A splint was located under a heap of belongings there. When asked if she used the splint, she shook her head no. (Photographic evidence obtained) She was asked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to develop and implement a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This failure directly impacted residents in four (Rooms 108, 120, 121, and 126) of 66 resident rooms with the potential to impact every resident with a personal refrigerator. The findings include: During an initial tour of the facility on 9/9/2024 from 9:30 AM through 12:00 PM, resident areas/rooms were observed: Multiple residents had personal refrigerators in their rooms. There were no temperature logs and expired food was located in the following rooms: Rooms 108, 120, 121, and 126. (Photographic evidence obtained for all) On 9/10/2024 at 11:57 AM, a personal refrigerator was observed in a room occupied by Residents #3 and #59. Both residents were non-verbal. Upon opening the refrigerator, a live roach was observed crawling on the bottom shelf. An interview was conducted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews, and staff interviews, the facility failed to maintain an infection prevention and control program designed to help prevent the transmission of communicable diseases and infections, by failing to perform appropriate hand hygiene during medication administration for two (Residents #13 and #33) of eight residents observed for medication administration from a total survey sample of 35 residents. The findings include: During another observation of medication administration on 9/11/24 at 1:10 PM, LPN H was observed preparing medication for Resident #13 at the nurses' station. LPN H reviewed the physician's orders and obtained two tablets of Buspirone 10 mg (milligrams), Clonazepam 0.5 mg, and Oxycodone-Acetaminophen 10-325 mg. She did not perform hand hygiene before popping medications into a medication cup. She then handed the medication cup with the medication to Resident #13 who was seated on his Rollator walker at the nurses' station. After the resident took the medication, LPN H discarded the cup in the trash but did not perform hand hygiene.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and an interview with the Business Office Manager, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for two (Resident #42 and Resident #22) of three residents sampled for review of Beneficiary Protection Notifications, from a total sample of 40 residents. The findings include: A review of Resident #42's medical record revealed an admission date of 5/26/2022. His last covered day for Medicare Part A services was 7/19/2022. The resident was discharged from Medicare A and remained in the facility. A review of Resident #22's medical record revealed an admission dated of 7/25/2022. Her last covered day of Medicare Part A services was 8/17/2022. The resident was discharged from Medicare A and remained in the facility. A record review of Beneficiary Protection Notifications for three randomly selected…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to ensure assessments accurately reflected residents' status for two (Resident #82 and Resident #93) of 40 residents sampled. Failure to accurately assess residents' care needs and medical status could result in a failure to provide needed care and services, resulting in complications and/or functional decline. The findings include: On 10/10/2022 at 2:45 p.m., Resident #82 was observed in his room lying in bed under the covers. He was greeted and he responded with garbled speech. At this time it was determined that the resident was not interviewable. Upon leaving Resident #82's room, Resident #93 was observed being escorted back to her room on a shower bed by two staff members. She was greeted and asked if she would agree to an interview once she returned to her room and got settled. She responded with grunts and giggles, reaching her hand out to make contact, and continuing to grunt, giggle, and motion for the surveyor's hand. At this time it was determined that the resident was not interviewable. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure each resident was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission, and that individuals identified with MD or ID were evaluated and received care and services in the most integrated setting appropriate to their needs for one (Resident #67) of 40 sampled residents. The findings include: A review of Resident #67's medical record on 10/10/22 at 2:36 p.m. and on 10/11/22 at 2:00 p.m. revealed no Pre-admission Screening and Resident Review Process (PASARR) present. On 10/11/22 at 2:50 p.m., the Director of Nursing (DON) stated, I could not find the PASARR. We are going to do a new one now. A record review was conducted for Resident #67 noting an admission date of 8/18/22. His diagnoses included pathological fracture, humerus, subs for fixture for routine heal; malignant neoplasm of unspecific part of unspecific bronchus or lung; type II diabetes mellitus, heart disease, bipolar disorder, major depressive disorder, and anxiety disorder. Resident #67 had physician's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and facility record review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all residents who consumed foods from the facility's kitchen. The facility failed to ensure that the dietary staff was trained and knowledgeable about the proper procedures for food storage and proper sanitation practices in the kitchen. Specific instruction on food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: An initial tour of the kitchen was conducted with Dietary Manager (DM) G on 10/10/2022 at 10:25 a.m. During the tour, the bread cart in the dry storage pantry had three open bundles of bread that were not dated/labeled. The fryer was covered with grease buildup and food debris. The floor underneath the fryer had soiled grease and a buildup of food debris covering the drainage area. During an interview at the time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.