St. Augustine Health and Rehabilitation Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on resident and staff interviews, a review of facility and resident records, and a review of the facility's policies and procedures titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, and Turning and Positioning the Residents, the facility failed to protect the resident's right to be free from neglect/deprivation of services by Certified Nursing Assistant (CNA) A. The facility failed to ensure sufficient safeguards and supervision to protect the resident's right to be free from neglect by failing to ensure that CNA A was aware of, and implemented, care plan interventions to prevent one resident (#1) from an avoidable fall with major injury (hip fracture), from a total of four residents reviewed for Activities of Daily Living (ADLs) assistance. [...]

Inspectors wroteBased on resident and staff interviews, a review of facility and resident records, and a review of the facility's policy and procedure titled Turning and Positioning the Residents, the facility failed to ensure that residents received adequate supervision and staff assistance to prevent avoidable falls with major injury (hip fracture) for one (Resident #1) of four residents reviewed for Activities of Daily Living (ADL) assistance. On 2/3/2026, Resident #1, who required 2-person assistance for bed mobility, sustained a fall from bed with a subsequent right hip fracture while Certified Nursing Assistant (CNA) A was providing peri-care. The CNA, working alone, turned the resident on his side in bed. The resident's leg slipped off the side of the bed pulling him to the floor. LPN B assessed the resident with no injuries immediately identified. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.