St Augustine Manor

In the surveyor’s words

From the most serious findings on record at St Augustine Manor, in the surveyor’s own words.

• Actual harm, isolatedF684Apr 2, 2026

  Based on record review, review of the Emergency Medical Service (EMS) Patient Care Report, review of hospital records, review of information from the National Institute of Health, review of information from the Centers for Disease Control, facility policy and interview, the facility failed to ensure Resident #195's vision/eye needs were comprehensively assessed, treated, and monitored to timely identify an acute change in condition and prevent a complication requiring hospitalization. This affected one resident (#195) of three residents reviewed for a change of condition. The facility census was 194.Actual harm occurred on 02/15/26 when Resident #195 was transferred to the hospital due to increased pain to her left eye, purulent drainage and loss of vision. […]

• No harm, potential for more than minimal, patternF698May 22, 2024

  Based on observation, interview and record review, the facility failed to provide hemodialysis care and services consistent with professional standards of practice related to the pre and post dialysis assessment and ongoing communication between the facility and the dialysis center for six (R154, R114, R98, R25, R106, R155) of six residents reviewed for dialysis. Findings include: 1.) Review of Resident #155 electronic Medical Diagnosis form indicated diagnoses of hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease (ESRD) dated 3/7/2023, dependence on renal dialysis dated 3/7/2023 and ESRD dated 8/10/2023. Quarterly Minimum Data Set (MDS) signed and locked on 12/15/23 at 3:00 p.m. […]

• No harm, potential for more than minimal, patternF880May 10, 2023

  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… […]

• No harm, potential for more than minimal, isolatedF690Apr 2, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF880Apr 2, 2026

  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. […]