St Augustine Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of the facility policy the facility failed to ensure Resident #195's urinary tract infection was treated properly with antibiotics per physician orders. This affected one resident (Resident #195) out of three residents reviewed for antibiotic administration. The facility census was 194.Findings include:Review of Resident #195's closed medical record revealed an admission date of 09/23/25 and diagnoses included history of Transient Ischemic Attack (TIA) and cerebral infarction without residual deficits, other incomplete lesion at C2 level of cervical spinal cord, systemic lupus erythematosus, major depressive disorder and type two diabetes mellitus with diabetic neuropathy. Resident #195 was discharged from the facility on 02/15/26.Review of Resident #195's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #195 was cognitively intact. Resident #195 required set up and clean-up assistance with eating and oral hygiene and substantial to maximal…

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 observation, interview and record review the facility failed to ensure enhanced barrier precautions were followed for Resident #65. This affected one resident (#65) of three residents observed for infection control. The facility census was 194.Findings include:Review of Resident #65's medical records revealed an admission date of 06/08/17 with diagnoses including gastrostomy (feeding tube), right sided paraplegia, muscle weakness and dysphagia (difficulty swallowing).Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had impaired cognition. Resident #65 was dependent with toileting, bathing and transfers. Review of care plan dated 03/18/26 revealed Resident #65 required Enhanced Barrier Precautions (EBP) related to device. Interventions included appropriate signage on residents door, and instruct caregivers to wear disposable gowns and gloves during physical contact with resident. Review of current physician orders for March 2026 revealed Resident #65 was ordered EBP due to…

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 4.) During observation and interview with R154 on 5/21/24 at approximately 5:05pm, R154 stated he goes to dialysis (a treatment for people whose kidneys are failing). R154 stated, Yes, three times [a week] Monday, Wednesday, Friday. When asked about his dialysis access site, R154 showed the surveyor his right upper arm. The site was covered with a dressing and secured with a tape. R154 stated he would get weighed at the dialysis unit. When asked if staff had been checking his vital signs when he returned from dialysis, R154 stated, No. R154 explained that staff checked him in the morning before but not after his dialysis treatment. Review of R154's Medical Diagnosis in Point Click Care (PCC, healthcare software and electronic health record) included end stage renal disease (kidney failure) and dependence on renal dialysis. Review of R154's quarterly Minimum Data Set (MDS), a federally mandated assessment tool) dated 4/29/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact…

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 observation, record review and interview, the facility failed to maintain dignity and respect at all times for Resident #62 and R448 by ensuring urinary drainage bags were covered. This affected two residents (#62 and R448) of two residents reviewed for dignity. The facility census was 188. Findings include: 1. Review of the medical record for Resident #62 revealed an admission date of 12/19/23 with diagnoses that included quadriplegia, dysphagia, and neuromuscular dysfunction of the bladder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was alert and oriented to person, place, time, and was dependent on staff for Activities of Daily Living (ADLs). Review of the care plan dated 11/17/16 revealed Resident #62 was at risk for skin breakdown related to quadriplegia with interventions that included providing incontinence care every 2 hours and as needed. Review of the physician orders dated 02/18/24 revealed an order to provide incontinence care every two hours and as…

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 observation, record review, and interview, the facility failed to ensure a comprehensive care plan, physician orders, and interventions of monitoring and evaluation was in place for Resident #144's hand restraint. This affected one resident (Resident #144) of two residents reviewed for restraint use. The total census was 188. Findings include: Record review of Resident #144 revealed he admitted to the facility 10/04/23 and had diagnoses including sepsis, dementia, and tracheostomy status. Review of Resident #144's comprehensive care plan revealed the resident had a tracheostomy due to respiratory failure with an intervention initiated on 10/17/23 for bilateral hand mitts at all times to prevent decannulation. Remove and provide care every two hours and as needed. The care plan had not been revised and did not include specific interventions as to how often to monitor and evaluate the use of the restraint. Review of Resident #144's restraint assessment dated [DATE] revealed he required PRN (as-needed)…

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 observation, record review, interview, facility policy review, and review of the Centers for Disease Control (CDC) guidance, the facility failed to maintain proper infection control procedures for enhanced barrier precautions and failed to ensure the multi-use glucometer blood testing (BGT) machine was disinfected and sanitized effectively to prevent the potential for cross-contamination of blood borne pathogens. This affected Resident #162 who was in enhanced barrier precautions of 28 residents with physician orders for enhanced barrier precautions residing on the fourth floor including Resident #25, #31, #33, #63, #87, #91, #146, #149, #159, #162, #180, #196, #198, #200, #354, #358, #454, #455, #456, #457, #459, #460, #462, #463, #466, #468, #469 and had the potential to affect an additional eighteen residents residing on the 4th floor who were not in enhanced barrier precautions or isolation precautions and the finding affected Resident #166 who received a BGT on the 2 [NAME] Unit and had the…

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 observation, record review and interview the facility failed to ensure call lights were within reach and accessible for Residents #14, and #72. This affected two residents (#14 and #72) of 197 residents reviewed for call light placement. The facility census was 197. Findings include: 1. Record review revealed Resident #14 was admitted on [DATE] to the facility with diagnoses that included but not limited to seizures, hemiplegia, epilepsy, and multiple fractures of the pelvis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 was moderately cognitively impaired and required extensive assistance of two staff for mobility, transfer, and toilet. Observation on 05/07/23 at 11:45 A.M. revealed Resident #14 was lying in bed. Resident #14's call light was observed lying on nightstand and not within reach of resident. Resident # 14 stated that she was getting over pneumonia. At the time of observation, Licensed Practical Nurse (LPN) #626 verified call light was…

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 observation, record review and interview, the facility failed to ensure wound care was completed as ordered. This finding affected one (Resident #143) of three residents reviewed for wounds. Findings include: Review of Resident #143's medical record revealed she was readmitted on [DATE] with diagnoses including diabetes, difficulty in walking and chronic obstructive pulmonary disease. Review of Resident #143's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited intact cognition. Review of Resident #143's physician orders revealed an order dated 02/20/23 to cleanse the left lower extremity skin tear with normal saline, pat dry, apply an adaptic (non stick dressing) followed by a foam dressing three times a week and as needed. The wound care was due every day shift on Monday, Wednesday and Friday. Review of Resident #143' treatment administration records (TARS) from 05/01/23 to 05/08/23 revealed the skin tear wound treatment was documented as completed on 05/05/23 on the TAR.…

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 observation, record review and interview, the facility failed to ensure Resident #165's pressure relieving foam boots were implemented as ordered. This finding affected one (Resident #165) of two residents reviewed for pressure wounds. The facility census was 197. Findings include: Review of Resident #165's medical record revealed he was admitted on [DATE] with diagnoses including muscle weakness, aphasia following a cerebral infarction and diabetes insipidus. Review of Resident #165's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited a memory problem. The medical record did not reveal current pressure ulcer wounds. Review of Resident #165's physician orders revealed an order dated 11/28/22 for pressure reduction boots to the bilateral feet as a preventative measure and check for placement. Review of Resident #165's Skin Care Plan indicated he was at risk for the development of skin breakdown and the intervention dated 11/29/22 indicated to apply pressure reduction boots to both…

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 record review and interview, the facility failed to ensure Resident #193 was provided adequate supervision during care to prevent a fall. This finding affected one (Resident #193) of two residents reviewed for falls. The facility census was 197 Findings include: Review of Resident #193's medical record revealed he was admitted [DATE] and readmitted on [DATE] with diagnoses including post traumatic seizures, muscle weakness and aphasia. Review of Resident #193's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated he exhibited severe cognitive impairment and required extensive two person assist for bed mobility and toilet use. He required total dependence two person assist for transfers and total dependence one person assist for dressing and eating. Review of Resident #193's physician orders revealed an order dated 11/16/22 and discontinued 05/04/23 to transfer the resident with a Hoyer mechanical lift with the assistance of two staff members every shift. Review of Resident #193's Morse Fall…

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 observation, record review and interview, the facility failed to ensure a medication error rate of less than 5% (percent). This finding affected two (Residents #75 and #125) of six residents observed for medication administration. A total of 26 medications were administered with two errors for a medication error rate of 7.69%. Findings include: 1. Review of Resident #125's medical record revealed he was readmitted on [DATE] with diagnoses including type two diabetes, end stage renal disease and muscle weakness. Review of Resident #125's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited intact cognition. Review of Resident #125's physician orders revealed an order dated 10/09/22 to administer lispro insulin (fast acting) if the blood sugar was zero to 149 administer then administer no units; 150 to 199 administer one unit; 200 to 249 administer two units, 250 to 299 administer three units, 300 to 349 administer five units, 350 to 399 administer seven units and if greater than 400…

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 record review and interview the facility failed to ensure advance directives for Resident #64 were accurately and consistently noted throughout the resident's medical record. This affected one resident (#64) of one resident reviewed for advance directives. Findings include: Review of the medical record for Resident #64 revealed the resident was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), morbid obesity, acute respiratory failure with hypoxia, and obstructive sleep apnea. Review of Resident #64's electronic physician's orders, dated 09/25/19 revealed an advance directive for Do Not Resuscitate Comfort Care- Arrest (DNRCC-Arrest), resuscitative therapies before an arrest, but not during or after an arrest. Review of the hard copy of medical record for Resident #64 revealed a signed advance directive for Do Not Resuscitate Comfort Care (DNRCC), care that eases pain and suffering but no resuscitative therapies. Interview on 12/03/19 at 8:52 A.M. with…

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 observation, record review and interview the facility failed to ensure Resident #72, who had a urinary (Foley) catheter had timely orders, assessments and documentation of care appropriate for the management of the catheter. This affected one resident (#72) of one resident reviewed for urinary catheter care. Findings include: Record review for Resident #72 revealed the resident was admitted to the facility on [DATE] with diagnoses including pressure ulcer of the hip, cognitive communication deficit, and major depressive disorder. Review of the diagnosis list revealed no diagnosis that was appropriate for long-term Foley use (such as neuromuscular bladder dysfunction, obstructive uropathy, or other diagnoses involving a blockage of the bladder or failure in its function). Review of the resident's progress notes revealed on 10/12/19 the resident experienced urinary retention and staff inserted a Foley. There were no physician orders received in regards to the Foley to remain in place or to receive regular…

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, record review and interview the facility failed to provide Resident #171 with a comfortable home like environment. This affected one resident (#171) of 79 residents who resided on the second floor unit. Findings include: A tour of the environment was conducted with the Outside Electrical Contractor, (OEC) #500 who was an employee of the facility's maintenance team was conducted on 12/05/19 from 12:05 P.M. to 12:20 P.M. During the tour, observation of Resident #171's room revealed wall damage under the face bowl in need of plastering, sanding and painting. While standing in front of the face bowl, the bottom portion of the wall to the right was damaged and the lath and plaster screen used for wall plastering was exposed. Review of the daily maintenance work request log from 10/2019 to 12/5/2019 revealed no request for maintenance work for the room belonging to Resident #171. Interview with (OEC) #500 on 12/05/19 at 12:21 P.M. revealed all staff were responsible for reporting any maintenance concerns regarding the residents' room. Moreover, the maintenance…

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.