Cycle 1
Health 2025-08-06 · Fire 2025-08-06
2 health deficiencies
Top issue: Infection Control (1 deficiency)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Saint Augustine, FL
Westminster St Augustine
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
230 Towerview Drive, Saint Augustine, FL
(904) 940-4801
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
27
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Westminster Communities Of Florida
Operator or chain grouping
Approved since
2002-01-03
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
8 facilities
Chain averages 4 overall / 4 health / 5 staffing / 5 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
0.87
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.72
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.30
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.01
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.83
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.92
CMS adjusted RN staffing hours
Adjusted total hours
4.55
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
19%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,182
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9939
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.25
Baseline 18.30% · Performance 20.39% · Measure score 2.25 · Achievement 2.25 · Improvement 0
Healthcare-associated infections
0.50
Baseline 5.96% · Performance 7.68% · Measure score 0.50 · Achievement 0.50 · Improvement 0
Total nurse turnover
10
Baseline 40.00% · Performance 20.00% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
3.66
Performance 4.12 hours · Measure score 3.66 · Achievement 3.66 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.92% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 165 · Observed rate 9.7% · Lower 95% interval 8.52% |
| Discharge to community | 63.33% |
50.57%
12.8 pts better
|
Better than the National Rate · Eligible stays 140 · Observed rate 62.86% · Lower 95% interval 56.17% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 103 · Denominator 103 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 103 |
| Discharge self-care score | 77.46% |
53.69%
23.8 pts better
|
Numerator 55 · Denominator 71 |
| Discharge mobility score | 61.97% |
50.94%
11 pts better
|
Numerator 44 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 103 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.68% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 106 · Observed rate 7.55% · Lower 95% interval 4.59% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 62 |
| Staff flu vaccination coverage | 97.33% |
42%
55.3 pts better
|
Numerator 73 · Denominator 75 |
| Discharge function score | 71.83% |
56.45%
15.4 pts better
|
Numerator 51 · Denominator 71 |
| Transfer of health information to provider | 96.55% |
95.95%
0.6 pts better
|
Numerator 28 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 61 · Denominator 61 |
| Resident COVID-19 vaccinations up to date | 34.55% |
25.2%
9.3 pts better
|
Numerator 19 · Denominator 55 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
2.1
1.5 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.2 · Expected 0.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.2
0.3 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 0.7 · Expected 0.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
2.6%
0.9 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.5% |
3.7%
0.2 pts better
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.5% |
| 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 · 4Q avg 0.0% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.6% |
12.5%
6.1 pts worse
|
19.8%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.6% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
5.1%
5.1 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
9.3%
1.2 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 7.3% · Expected 10.1% · 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 | 100.0% |
94.7%
5.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.7% |
26.2%
8.5 pts better
|
23.9%
6.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.7% · Observed 14.6% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-05 · Fire 2024-01-05
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-06-02 · Fire 2022-06-02
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-06
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-06
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-06
E42 · Emergency Preparedness Deficiencies
Fire Safety
Meet the requirements of an integrated health system.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-06
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-06
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-06
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-05
D · Potential for more than minimal harm
2022-06-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-07-02
Penalties and ownership
What sits behind the stars
Ownership
Degross, Misty
Operational/Managerial Control · Individual
Doddridge, Donald
Corporate Officer · Individual
Faubel, Megan
Corporate Officer · Individual
Heise, David
Operational/Managerial Control · Individual
Hennis, Garry
Corporate Officer · Individual
Keith, Henry
Operational/Managerial Control · Individual
Keith, Henry
Corporate Director · Individual
Keith, Henry
Corporate Officer · Individual
Westminster Services Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Clyde E Lassen State Veterans Nursing Home
Saint Augustine, FL
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Bartram Crossing
Jacksonville, FL
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
St Augustine Health And Rehabilitation Center
Saint Augustine, FL
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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