Inspection Reports for
Westminster St. Augustine
235 Towerview Dr, St. Augustine, FL 32092, United States, FL, 32092
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% better than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 6, 2025
Visit Reason
The inspection was conducted to investigate complaints and grievances raised by residents regarding unresolved grievances and concerns about facility services.
Complaint Details
The investigation was triggered by complaints from Resident #4 about missing nightgowns and Resident #7 about discomfort with her wheelchair. Both grievances were not properly documented or resolved according to facility policy. The Social Services Director and other staff confirmed lack of grievance documentation and follow-up.
Findings
The facility failed to properly record, address, and resolve grievances for two residents regarding missing personal items and wheelchair discomfort. Additionally, the facility failed to ensure proper hand hygiene and use of personal protective equipment during care of a resident with a PICC line.
Deficiencies (2)
F 0585: The facility failed to honor residents' rights to voice grievances without discrimination or reprisal and did not properly document or resolve grievances for two residents regarding missing nightgowns and wheelchair discomfort.
F 0880: The facility failed to implement an infection prevention program by not performing hand hygiene between glove changes and not wearing the required gown when accessing a resident's PICC line.
Report Facts
Residents in survey sample: 15
Nightgown cost: 69
BIMS score: 15
Years worked: 20
Years worked: 4.5
Normal Saline Flush volume: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Grievance Officer | Confirmed grievance process and lack of grievance documentation for Resident #4 |
| Certified Nursing Assistant E | Certified Nursing Assistant | Interviewed regarding Resident #7's wheelchair complaint |
| Licensed Practical Nurse B | Licensed Practical Nurse | Reported awareness of Resident #7's wheelchair complaint |
| Therapy Program Director | Therapy Program Director | Confirmed Resident #7's complaint about wheelchair and grievance reporting process |
| Licensed Practical Nurse A | Licensed Practical Nurse | Observed failing to perform hand hygiene and wear gown when accessing Resident #1's PICC line |
| Director of Nursing | Director of Nursing | Stated expectations for hand hygiene and barrier precautions |
| Administrator | Administrator | Explained grievance process and facility's approach to resolving issues verbally |
Inspection Report
Deficiencies: 3
Date: Dec 16, 2024
Visit Reason
State-compiled facility profile showing 13 inspections from 2013-07 to 2024-12 with deficiency history.
Findings
Across multiple inspections, the facility had a mix of deficiency statuses including cited, corrected, and no deficiencies, with the most recent inspection showing no deficiencies.
Deficiencies (3)
Deficiencies Cited
Deficiencies Corrected
No Deficiencies
Report Facts
Inspections on page: 13
Inspection Report
Routine
Deficiencies: 0
Date: Dec 16, 2024
Visit Reason
No deficiencies noted during this inspection.
Findings
No deficiencies noted during this inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 5, 2024
Visit Reason
Annual inspection survey of Westminster St Augustine nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 1
Date: Jul 7, 2022
Visit Reason
Deficiency related to staff in-service training with Class 3 severity.
Findings
Deficiency related to staff in-service training with Class 3 severity.
Deficiencies (1)
Tag A0081 — TRAINING - STAFF IN-SERVICE
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 2, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to adequately monitor resident behaviors for a resident receiving antipsychotic medications.
Complaint Details
The complaint investigation found that the facility did not have current orders or documentation for behavior monitoring for antipsychotic medications for Resident #16. The Director of Nursing confirmed missing documentation and noted that electronic medical records sometimes dropped orders. Previous reviews of antipsychotic monitoring had occurred but not recently.
Findings
The facility failed to monitor behaviors for one resident receiving antipsychotic medication as required. Documentation and orders for behavior monitoring were missing despite active medication orders and care plan interventions.
Deficiencies (1)
F 0757: The facility failed to ensure each resident's drug regimen was free from unnecessary drugs by not adequately monitoring behaviors for a resident receiving antipsychotic medication. Documentation and physician orders for behavior monitoring were absent.
Report Facts
Residents receiving antipsychotic medication in sample: 11
Days antipsychotic medication received: 7
Medication dosage: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agency Licensed Practical Nurse (LPN) A | Interviewed about behavior monitoring expectations for residents on antipsychotic medications | |
| Director of Nursing (DON) | Interviewed regarding missing orders and documentation for behavior monitoring |
Inspection Report
Routine
Deficiencies: 1
Date: Oct 24, 2019
Visit Reason
Deficiency related to staff in-service training with Class 3 severity.
Findings
Deficiency related to staff in-service training with Class 3 severity.
Deficiencies (1)
Tag A0081 — TRAINING - STAFF IN-SERVICE
Inspection Report
Deficiencies: 3
Date: Nov 30, 2017
Visit Reason
Multiple deficiencies including staff in-service training, records maintenance, and background screening with Class 3 and Class 4 severities.
Findings
Multiple deficiencies including staff in-service training, records maintenance, and background screening with Class 3 and Class 4 severities.
Deficiencies (3)
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0160 — RECORDS - FACILITY
Tag CZ814 — BACKGROUND SCREENING CLEARINGHOUSE
Inspection Report
Routine
Deficiencies: 1
Date: Jul 22, 2013
Visit Reason
Deficiency related to training on Do Not Resuscitate Orders with Class 3 severity.
Findings
Deficiency related to training on Do Not Resuscitate Orders with Class 3 severity.
Deficiencies (1)
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
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