Cycle 1
Health 2024-09-12 · Fire 2024-09-12
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Saint Augustine, FL
St Augustine Health And Rehabilitation Center
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
51 Sunrise Blvd, Saint Augustine, FL
(904) 824-4479
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
113
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
1977-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.39
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
4.42
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,983
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9883
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.62% · Performance 22.50% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.79
Baseline 6.00% · Performance 6.70% · Measure score 3.79 · Achievement 3.79 · Improvement 0
Total nurse turnover
6.41
Performance 37.50% · Measure score 6.41 · Achievement 6.41 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.56
Baseline 4.59 hours · Performance 4.09 hours · Measure score 3.56 · Achievement 3.56 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.32% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 136 · Observed rate 13.24% · Lower 95% interval 8.15% |
| Discharge to community | 42.55% |
50.57%
8 pts worse
|
No Different than the National Rate · Eligible stays 71 · Observed rate 35.21% · Lower 95% interval 32.54% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.65% |
95.27%
3.4 pts better
|
Numerator 73 · Denominator 74 |
| Falls with major injury | 1.35% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 74 |
| Discharge self-care score | 45.65% |
53.69%
8 pts worse
|
Numerator 21 · Denominator 46 |
| Discharge mobility score | 36.96% |
50.94%
14 pts worse
|
Numerator 17 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 1.35% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 74 · Adjusted rate 1.06% |
| Healthcare-associated infections requiring hospitalization | 6.7% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 5.26% · Lower 95% interval 4.01% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 120 |
| Staff flu vaccination coverage | 4.61% |
42%
37.4 pts worse
|
Numerator 7 · Denominator 152 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 23 · Denominator 46 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 23.68% |
25.2%
1.5 pts worse
|
Numerator 9 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.4 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.2
0.9 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
97.8%
2 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
2.6%
0.7 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.9% · Q3 2.8% · Q4 3.8% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.7% |
3.7%
2 pts worse
|
11.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 6.3% · Q3 3.9% · Q4 6.4% · 4Q avg 5.7% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
5.9%
0.1 pts better
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 5.3% · Q3 9.0% · Q4 6.3% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.2% |
15.7%
7.5 pts better
|
19.6%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 6.4% · Q3 6.2% · Q4 8.8% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.9% |
9.8%
6.9 pts better
|
16.7%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.2% · Q3 1.5% · Q4 1.4% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.5% |
11.7%
3.2 pts better
|
16.3%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 12.2% · Q3 7.9% · Q4 2.8% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.6% |
9.8%
3.2 pts better
|
14.9%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 7.4% · Q3 10.4% · Q4 2.9% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.4%
0.1 pts worse
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 0.6% · Q4 0.6% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
0.8%
0.4 pts worse
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.0% · Q3 1.9% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.9% |
12.5%
3.6 pts better
|
19.8%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 13.8% · Q3 8.8% · Q4 4.7% · 4Q avg 8.9% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
5.1%
2.5 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 8.2% · Q3 6.8% · Q4 5.8% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
94.3%
2.3 pts better
|
81.7%
14.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 95.3% · Q3 97.6% · Q4 98.8% · 4Q avg 96.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
9.3%
About the same
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 10.5% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
94.7%
0.4 pts worse
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.0% |
26.2%
0.2 pts better
|
23.9%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.0% · Observed 28.1% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-13 · Fire 2022-10-13
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2021-03-11 · Fire 2021-03-11
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-09-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-09-12
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-12
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-18
D · Potential for more than minimal harm
2022-10-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-10-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-09-12
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-09-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-09-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-12
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-12
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-12
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-18
D · Potential for more than minimal harm
2022-10-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-10-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-10-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-10-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-13
F · Potential for more than minimal harm
2021-03-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-04-11
E · Potential for more than minimal harm
2021-03-11
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2021-04-11
D · Potential for more than minimal harm
2021-03-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-04-11
Penalties and ownership
What sits behind the stars
Ownership
Estes, James
5% Or Greater Direct Ownership Interest · Individual
James N Estes Jr Family Dynasty Tr No 2
5% Or Greater Direct Ownership Interest · Organization
Jennifer E Agee Family Dynasty Tr No 2
5% Or Greater Direct Ownership Interest · Organization
James Norman Estes Jr Tr
5% Or Greater Direct Ownership Interest · Organization
Jennifer Lee Estes Tr 031093
5% Or Greater Direct Ownership Interest · Organization
Estes, James
Corporate Officer · Individual
Hughes, Thomas
Operational/Managerial Control · Individual
Hughes, Thomas
W-2 Managing Employee · Individual
Long, Phillip
Corporate Officer · Individual
Mcvea, Cheri
Operational/Managerial Control · Individual
Mcvea, Cheri
Corporate Director · Individual
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Regions Bank
5% Or Greater Security Interest · Organization
Schneider, Julie
Operational/Managerial Control · Individual
Schneider, Julie
Corporate Director · Individual
Toney, Darin
Operational/Managerial Control · Individual
Toney, Darin
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Ponce Therapy Care Center And Rehab, The
Saint Augustine, FL
5-star overall rating with 5-star inspections
#2
Lilac At Bayview, The
Saint Augustine, FL
2-star overall rating with 2-star inspections with $125,355 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Moultrie Creek Nursing And Rehab Center
Saint Augustine, FL
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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