St Augustine Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at St Augustine Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 5, 2026

  Based 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… […]

• Immediate jeopardy, isolatedF689Mar 5, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812May 21, 2026

  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. […]

• No harm, potential for more than minimal, widespreadF908Sep 12, 2024

  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 [DATE] 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 ,d+[DATE] and ,d+[DATE]. […]

• No harm, potential for more than minimal, widespreadF812Mar 11, 2021

  Based on observations and staff interviews, the facility failed to store dishware, covered or inverted, in a location where it was not exposed to splash, dust and other contamination. The facility failed to maintain two of the three microwaves used for residents, in a safe and sanitary manner. This deficient practice potentially affected all residents in the facility who took their meals from the facility's kitchen and/or obtained any food/beverage items from the North or South Unit nourishment rooms. The findings include: An initial tour of the kitchen was conducted on 3/8/2021 at 9:55 a.m. with the Dietary Manager (DM). During the tour, a plate dispenser was observed with no cover and plates were stored face-up. […]