Westminster St Augustine

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF585Aug 6, 2025

  Based on resident and staff interviews and resident/facility record reviews, the facility failed to record, address, and resolve grievances for two (Residents #4 and #7) of two residents reviewed for grievances from a total survey sample of 15 residents. The findings include: 1. On 08/04/2025 at 10:50 AM, an interview was conducted with Resident #4, who reported the facility had lost three of her nightgowns purchased with her own money for $69.00 each that she reported to the laundry supervisor who was no longer working for the facility. She stated she purchased the nightgowns to keep her warm and without them, the facility staff would place her in a hospital gown, and she got cold easily. One nightgown was found, but the other two, a cream-colored gown and a blue-colored gown were not. […]

• No harm, potential for more than minimal, isolatedF880Aug 6, 2025

  Based on observation, interview and record review, facility staff failed to 1) Properly perform hand hygiene between disposable glove changes for one (Resident #1) of six residents observed during medication administration, and 2) Ensure to don the proper personal protective equipment for accessing a Peripherally Inserted Central Catheter (PICC) line for one (Resident #1) of one resident with a PICC line.The findings include: During an observation on 08/05/2025 at 11:10 AM, Licensed Practical Nurse (LPN) A completed Resident #1's blood glucose monitoring and removed the gloves from both hands. LPN A disposed of the used gloves and donned a new pair of gloves without performing hand hygiene in between. […]

• No harm, potential for more than minimal, isolatedF757Jun 2, 2022

  Based on record review and interviews, the facility failed to adequately monitor resident behaviors for one resident (#16) receiving antipsychotic medications from a total sample of 11 residents. The findings include: A review of Resident #16's medical record revealed an admitted [DATE] with a readmission on 11/29/19. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the May 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record did not reveal any orders for behavior monitoring for the ordered medication. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 5/2/22, revealed that Resident #16 received antipsychotic medication on seven of seven days during the assessment lookback period. […]

• No harm, potential for more than minimal, isolatedF656Mar 24, 2021

  Based on observations, record reviews and a staff interview, the facility failed to implement the comprehensive, person-centered care plan in order to meet residents' needs for one (Resident #14) of one resident reviewed for use of supplemental oxygen, from a total of 17 residents in the sample. The findings include: 1. On 3/22/2021 at 11:25 am, Resident #14 was observed lying in bed in his room. An oxygen concentrator was present with a clear nasal cannula, which was inserted in the resident's nostrils. The concentrator was set to administer oxygen at 2 liters per minute. A second observation of Resident #14 on 3/22/2021 at 3:06 pm, revealed the resident sitting in a recliner in his room with the nasal cannula applied. […]

• No harm, potential for more than minimal, isolatedF697Mar 24, 2021

  Based on observations, interviews and record reviews, the facility failed to adequately manage pain for one (Resident # 17) of one resident reviewed for pain management, from a total of 17 residents in the sample. The findings include: A review of Resident #17's medical record revealed she was admitted on [DATE]. Her admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent comprehensive Minimum Data Set (MDS) assessment, dated 3/9/21, indicated the resident's cognition was impaired and she required extensive to total assistance with activities of daily living. She also received hospice services. On 3/22/21 at 10:24 AM, Resident #17 was observed lying in bed. She could be heard from the hallway yelling out repeatedly. Her speech was incoherent. […]