Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harborview Health Center Of Augusta during CMS and state inspections, most recent first.
Infection control practices were not followed in the laundry area, where fans with grey particulate matter were blowing onto clean linens. Wash basins were also found unbagged and unlabeled in multiple resident bathrooms, including stacked and uncovered basins. In addition, an LPN performed tracheostomy suctioning without sterile technique for a resident with trach status, while the trach circuit hose and water collection bag were observed on the floor.
Unclean PTAC filters were observed in multiple resident rooms, with heavy gray, fuzzy debris noted on units in rooms on the 300, 400, and 500 halls. The facility’s preventive maintenance policy and online maintenance platform called for monthly filter cleaning, and the Maintenance Director confirmed the debris was significant and that the PTAC filters had not been cleaned recently.
Unauthorized Medication Kept at Resident Bedside: A resident with renal disease, DM2, HF, HTN, hyperkalemia, and bipolar disorder had an OTC calcium carbonate bottle on the bedside nightstand with no name or open date. The EMR showed no assessment for self-administration and no MD order allowing bedside meds. The resident said he kept and took the medication himself before meals because nurses never gave it to him, and an LPN, the Staff Development Coordinator, and the DON confirmed the medication was at the bedside.
A resident with major depressive disorder, anxiety, unspecified psychosis, suicidal ideations, and moderate cognitive impairment was not assessed and referred for PASARR II services after admission. The resident said he did not receive counseling or psychological assistance for anxiety, an LPN said there were no mental health orders, and the Social Services Director stated she did not apply for PASARR II when a psychiatric diagnosis was received after admission.
A resident who was cognitively intact and needed help with bathing and personal hygiene did not receive consistent ADL care. Staff records showed limited bath documentation, no toenail referral was made initially, and an observation found the resident’s toenails long and untrimmed. The resident stated she had not had a shower since admission and had not been offered bed baths or toenail grooming, while CNAs and an LPN gave inconsistent accounts of the bathing documentation.
Expired insulin vials were found on two medication carts, including opened Novolog vials on the 200 Hall cart and an insulin vial on the 400 Hall cart. The facility policy required checking expiration dates and notifying the manager if expired, and the Administrator, DON, and ADON all stated that nurses were expected to check carts daily, remove expired meds, and reorder replacements.
A resident with advanced cancer and pressure ulcers did not receive consistent pain management due to unavailability of prescribed fentanyl patches on multiple occasions and infrequent administration of hydromorphone, despite orders for more frequent dosing. Staff did not consistently assess pain or notify the physician about missed medications, resulting in the resident experiencing pain during care.
During a kitchen inspection, multiple food items in both the refrigerator and freezer were found to be unsealed, unlabeled, or undated, including containers of dry goods, prepared foods, and refrigerated items. These deficiencies had the potential to affect nearly all residents receiving meals from the kitchen.
Two residents did not receive multiple ordered medications, including pain, antibiotic, cardiac, and seizure medications, due to unavailability. Staff and nursing leadership were unaware of the missed doses, and the facility lacked a procedure for handling unavailable medications, despite pharmacy contract provisions for emergency supply.
Insulin pens and vials on two medication carts were found without proper pharmacy labels, open dates, or expiration dates, and several were used past their expiration. An LPN confirmed that expired or unlabeled insulin should have been discarded, while the DON stated that nurses are expected to label and check insulin before use. These deficiencies were observed during inspection and confirmed through staff interviews.
A resident was not provided with written information about their right to accept or refuse medical or surgical treatment or to formulate an advance directive, as required by facility policy. The DON confirmed that no documentation existed to show this information was given at admission or re-admission.
A resident with multiple medical conditions became bedbound and cognitively impaired after hospital readmission, but the care plan was not updated to include interventions for pressure ulcer prevention. Despite developing three pressure ulcers and requiring substantial assistance, the care plan only listed general skin care measures, and no further Braden Scale assessments or documentation of repositioning were completed. Staff interviews and observations confirmed that necessary interventions, such as heel elevation, were not consistently implemented or documented.
A resident with multiple medical conditions and a decline in mobility and cognition after hospital readmission did not receive updated pressure ulcer prevention interventions. Despite being bedbound and requiring substantial assistance, the resident was observed repeatedly without heel elevation, and there was no documentation of repositioning or reassessment of pressure ulcer risk. The resident subsequently developed multiple pressure ulcers, and the facility lacked a policy on pressure ulcer prevention.
Two residents with significant risk factors, including diabetes and impaired mobility, did not receive ongoing podiatry services as recommended, despite documented needs for routine foot care and follow-up. Both residents experienced long, thickened, and sometimes painful toenails, and staff confirmed that podiatry visits had not occurred for some time, with neither resident listed for upcoming podiatry appointments.
A resident with a tracheostomy was found to have dirty and improperly maintained respiratory equipment, including an oxygen concentrator with dried particles and a dusty filter, as well as outdated suction tubing and an unbagged Yankauer suction tip. Staff confirmed that cleaning and supply changes were not performed as required by policy and physician orders.
Staff did not adhere to infection control protocols, including failure to wear gowns and perform hand hygiene during personal care and wound care for residents on Enhanced Barrier Precautions, and did not sanitize blood pressure cuffs between residents. These actions were not in accordance with facility policies, as confirmed by staff and leadership interviews.
The facility failed to ensure the confidentiality of personal and medical records for two residents. Medication cards containing sensitive information were left unattended on a medication cart, accessible to residents, staff, and visitors. An LPN confirmed the cards were improperly handled, and the Administrator acknowledged the expectation for proper disposal to maintain privacy.
The facility failed to follow its grievance procedures for a moderately cognitively impaired resident. The resident's representative filed a grievance about late medication administration, a dirty environment, a broken toilet seat, and the resident not being changed timely. The Concern Form lacked documentation of follow-up actions, dates, and whether the individual was satisfied with the resolution. Staff interviews revealed inconsistencies and a lack of clear communication regarding the grievance process.
A resident with a stage IV sacral pressure ulcer was found without a dressing, leaving the wound exposed to urine and feces. The facility's policy required dressings to be replaced if soiled or dislodged, but staff failed to adhere to this policy. Interviews revealed that staff were unaware of the missing dressing and did not notify a nurse, leading to a deficiency in care.
The facility failed to ensure that clinical records were complete and accurate for three residents. One resident had missing documentation for gabapentin administration, another had no documentation of intake on several dates, and a third had missing documentation for personal hygiene, bladder elimination, and the amount eaten on various dates. The Administrator confirmed the missing documentation and emphasized the need for accurate record-keeping.
Infection Control Failures in Laundry, Basin Storage, and Tracheostomy Care
Penalty
Summary
The facility failed to follow infection prevention and control practices in the laundry area when two fans in the laundry were observed with an accumulation of grey particulate matter on the fan grates while blowing onto a table containing clean linens, including sheets and towels. The observation was confirmed by the Housekeeping Supervisor and two Laundry Assistants. Later, the fans were removed from the laundry area. The facility also failed to properly store wash basins in multiple resident bathrooms on two halls. Wash basins were observed sitting on racks, stacked under sinks, and stacked on the floor in several bathrooms without being bagged or labeled. During interviews, a Unit Manager/LPN acknowledged the basins were stacked, uncovered, and unlabeled and stated this posed an infection control issue. CNAs reported they were unaware the basins needed to be labeled and bagged or admitted they forgot to do so, and the DHS confirmed the basins should have been labeled and bagged due to infection control concerns. The facility further failed to provide sterile tracheostomy care for a resident with critical illness myopathy, respiratory failure, COPD, and tracheostomy status. The resident required trach care every shift, trach ties every shift, and weekly trach circuit changes. Observations showed the trach circuit hose and water collection bag were on the floor on multiple occasions, and the suction canister was full. During observed tracheostomy suctioning, an LPN opened the suction kit, removed the sterile gloves, laid them on top of the open kit, donned them without sterile technique, and touched the outside of the tracheostomy while attempting to pass the catheter into the tracheostomy. The SDC RN and DON confirmed the need for sterile tracheostomy suctioning and that the circuit hose needed to be off the floor.
Unclean PTAC Filters in Resident Rooms
Penalty
Summary
The facility failed to ensure residents were provided with a safe, clean, and comfortable environment when Packaged Terminal Air Conditioner (PTAC) unit filters were found unclean in multiple resident rooms. Observations identified heavy gray, fuzzy debris on PTAC filters in three of nine rooms on 300 Hall, two of 16 rooms on 400 Hall, and one of 16 rooms on the 500 Hall. The report identified the affected rooms as [ROOM NUMBER] on 300 Hall, [ROOM NUMBERS] on 400 Hall, and [ROOM NUMBER] on the 500 Hall. The facility policy titled Preventive Maintenance Program stated that the Maintenance Director is responsible for developing and maintaining a schedule of maintenance services and assessing the physical plant to determine if preventive maintenance is required. The facility’s online maintenance platform listed a monthly schedule and instructions for cleaning the air filters. During interview, the Maintenance Director confirmed significant debris was present on the observed units and stated the PTAC filters were generally cleaned monthly but had not been cleaned recently. The Administrator stated the expectation was to follow the schedule in the online maintenance platform for cleaning the units and that maintenance was expected to clean the units and filters when they needed cleaning.
Unauthorized Medication Kept at Resident Bedside
Penalty
Summary
The facility failed to ensure that one sampled resident, R7, did not have unauthorized and unsecured medications at the bedside. R7 was admitted with diagnoses including renal disease, type 2 diabetes, heart failure unspecified, hypertension, hyperkalemia, and bipolar disorder. The resident’s comprehensive admission MDS showed a BIMS score of 15, indicating no cognitive impairment. However, the EMR contained no evidence that an assessment was completed to determine whether self-administration of medications was clinically appropriate, and there was no physician order for the resident to keep medications at the bedside for self-administration. During observations, surveyors found one bottle of over-the-counter calcium carbonate on R7’s bedside nightstand with no name or open date on it. The medication remained at the bedside on a later observation, and R7 stated that his doctor told him he needed it, that nurses at the facility never gave it to him, and that he kept it in his nightstand and took it himself before meals. An LPN and the Staff Development Coordinator confirmed the medication was still at the bedside, and the DON stated that medications brought from home were to be given to the nurse and that unauthorized medications found at the bedside should be removed immediately.
Failure to Complete PASARR II Assessment for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to assess and apply for PASARR II services for one sampled resident with psychiatric diagnoses. Review of the EMR showed the resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left side, COPD, major depressive disorder, general anxiety disorder, unspecified psychosis, and suicidal ideations. The resident’s quarterly MDS showed a BIMS score of 9, indicating moderate cognitive impairment, and Section GG documented the need for extensive assistance with ADLs due to pain and weakness. The care plan identified the resident as at risk for altered mood related to suicidal ideations, anxiety disorder, major depressive disorder, and unspecified psychosis. During interview, the resident stated he did not receive counseling or psychological assistance for anxiety. An LPN stated the resident did not have orders for mental health to see him. The Social Services Director stated she handled preadmission PASARR assessments, but if a resident received a mental health diagnosis after admission, she did not apply for a PASARR II assessment. The Administrator stated she was unaware the Social Services Director had not applied for PASARR II for residents with a psychiatric diagnosis after admission and confirmed the Social Services Director was responsible for that aspect of resident care.
Failure to Provide ADL Care and Nail Grooming
Penalty
Summary
Activities of daily living care was not provided for one dependent resident, R28, related to bed baths and nail care. The facility policy stated that a resident unable to carry out ADLs would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. R28’s MDS showed a BIMS score of 14, indicating she was cognitively intact, and her care plan identified that she needed assistance with grooming, bathing, and personal hygiene. The bath schedule listed her room for showers and baths on Tuesday, Thursday, and Saturday on the evening shift. Review of the shower and bath report showed R28 refused a bath on 05/16/2026 and had a bed bath completed on 06/02/2026 by CNA QQ, but the report did not show that her toenails were checked for podiatry referral. Podiatry visit lists did not include R28, and on 06/03/2026 the Social Service Director emailed the podiatry partner to add her to the list. During interviews, R28 stated on 06/01/2026 that she had not had a shower since admission and had not received bed baths or been offered or provided toenail grooming. On 06/02/2026, observation showed her toenails were long and untrimmed, and LPN AA confirmed this. CNA SS stated she provided a bed bath on 06/02/2026 but documented it based on R28’s response rather than confirming the exact date from daily charting. CNA QQ also confirmed providing a bed bath on 06/02/2026 but stated she was not aware she needed to check off additional observations and acknowledged R28’s toenails were long. CNA PP stated he administered bed baths to R28 but could not confirm the dates.
Expired insulin remained on medication carts
Penalty
Summary
Drugs and biologicals were not maintained in accordance with accepted storage and labeling practices when expired medications were found on two of four medication carts reviewed. Review of the facility policy titled Medication Administration stated that the expiration date should be identified and, if expired, the manager should be notified. During observation on 06/02/2026 at 7:56 AM, two opened Novolog insulin vials on the 200 Hall medication cart were found with expiration dates of 04/22/2026 and 05/09/2026, and this was confirmed with the LPN. On the 400 Hall medication cart, one insulin vial dated 05/27/2026 was observed and confirmed by the CMA and Unit Manager LPN. Interviews with the Administrator, DON, and ADON showed they expected the nurse assigned to the medication cart to check daily for expired medications, remove expired items, and reorder replacements from the pharmacy. The Administrator stated the nurses on the medication carts were expected to check daily for expired medications. The DON stated the label and expiration date should be checked on all medications and, if expired, removed from the cart and the pharmacy called for replacement. The ADON stated nurses should check expired medication daily, remove it from the cart, and reorder supplies before medications on the cart expire.
Failure to Provide Consistent Pain Management and Medication Availability
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple serious medical conditions, including colon cancer, bone cancer, lung cancer, chronic pain syndrome, and pressure ulcers. The resident had an order for a fentanyl transdermal patch to be applied every three days, but the medication was not available on several scheduled dates. Additionally, the resident's pain was not consistently assessed, and staff did not use a pain assessment tool appropriate for his cognitive status as outlined in facility policy. The resident was observed to be in pain, exhibiting nonverbal indicators such as moaning and grimacing, and was unable to verbally express his pain level due to moderate cognitive impairment. Despite having an order for hydromorphone to be administered every six hours as needed for pain, the resident only received this medication once daily. Staff, including the DON and an RN, were unaware that the fentanyl patches were not available on multiple occasions and did not realize the hydromorphone was not being administered as frequently as ordered. The resident's physician was not notified about the missed fentanyl doses or the ongoing pain management issues. As a result, the resident experienced pain, particularly during repositioning for wound care.
Failure to Properly Label, Date, and Seal Food Items in Kitchen Storage
Penalty
Summary
The facility failed to ensure that all food items in the refrigerator and freezer were properly sealed, labeled, and dated, as observed during a kitchen inspection. Four large plastic containers holding breadcrumbs, thickener, flour, and sugar were found without labels or dates. In the walk-in refrigerator, metal containers of watermelon, ketchup, and cucumbers were found to be outdated, and several other items including a bowl of icing, two sandwiches, a bag of sliced cheese, a bag of ham, poured glasses of iced tea, and a cooked pan of broccoli lacked labeling or dating, with the broccoli also not sealed to prevent air exposure. In the walk-in freezer, a box of biscuits was found unsealed and exposed to air. These issues were identified during an observation with the kitchen cook and confirmed in an interview with the Administrator, who acknowledged the need for staff education on labeling and dating procedures. A total of 110 out of 112 residents who received meals from the kitchen were potentially affected by these failures.
Failure to Ensure Medication Availability and Administration
Penalty
Summary
The facility failed to ensure that medications were consistently available and administered as ordered for two residents. For one resident, multiple medications including a fentanyl transdermal patch for pain, Flomax for urinary retention, levofloxacin as an antibiotic, and zolpidem tartrate for sleep were not available on several occasions as documented in the Medication Administration Record. The absence of these medications was confirmed through observation of the medication cart, which lacked the required narcotic patches and documentation, and through interviews with nursing staff who were unaware of the missing medications. The Director of Nursing and a registered nurse also stated they were not aware of the unavailability of these medications and noted that the new automated medication dispensing system did not have narcotics available for supply. A second resident did not receive several critical medications, including amiodarone, amlodipine besylate, metoprolol succinate ER, Keppra, and Eliquis, as ordered during her stay. The resident’s family member reported that medications were not available upon admission, and the Director of Nursing confirmed she had not been informed of the missed doses. Review of facility policy revealed there was no procedure in place for when a medication was not available, and the pharmacy contract indicated that drugs and supplies should be provided as required, including after-hours emergency deliveries. Despite these provisions, the facility did not ensure medication availability, and staff did not report the missing medications to nursing leadership.
Failure to Properly Label, Date, and Remove Expired Insulin
Penalty
Summary
Surveyors observed that insulin pens and vials on two medication carts were not properly labeled or dated in accordance with manufacturer recommendations and professional standards. Specifically, several insulin pens and vials lacked pharmacy labels, were not dated when opened, and some were found to be used past their expiration dates. The manufacturer's guidelines for various types of insulin, including glargine, Humalog, Lispro, Novolog, Aspart, and Toujeo Solostar, require that these medications be used within 28 days of being removed from refrigeration. Despite these requirements, multiple insulin products on both the 100-hall and 200-hall carts were either missing open dates, missing expiration dates, or had expired but were still present on the carts. During interviews, an LPN acknowledged that the insulins should have been discarded when expired or labeled when opened, but was unsure who was responsible for ensuring compliance. The DON stated that her expectation was for the nurse who removed the insulin from refrigeration to label it with the opened and expiration dates, and that nurses should always check expiration dates before administration. The failure to properly label, date, and remove expired insulin was directly observed and confirmed by staff interviews.
Failure to Provide Written Information on Advance Directives
Penalty
Summary
The facility failed to provide a resident and/or their representative with written information regarding the right to accept or refuse medical or surgical treatment and to formulate an advance directive. According to the facility's policy, staff are required to determine if a resident has an advance directive upon admission and, if not, to offer information about the right to create one. The policy also states that any decisions regarding the resident's choices should be documented in the medical record and communicated to the care team. However, the policy did not specify that this information must be provided in written form. Record review for one resident revealed no documentation that written information about advance directives or the right to accept or refuse treatment was provided at admission or re-admission. During an interview, the DON confirmed that there was no record of the resident receiving any information about advance directives, as the admission occurred under previous ownership and no documentation was available in the electronic medical record.
Failure to Update Care Plan and Implement Pressure Ulcer Prevention After Change in Condition
Penalty
Summary
The facility failed to update the care plan for a resident following a significant change in condition after hospital readmission, resulting in the development of three pressure ulcers. The resident, who had multiple medical diagnoses including rib and vertebral fractures, prostate cancer, and diabetes, was initially assessed as not at risk for pressure ulcers. However, after a hospitalization for deep vein thrombosis and pneumonia, the resident became bedbound, experienced cognitive decline, and required substantial assistance with mobility and activities of daily living. Despite these changes, the care plan was not revised to include specific interventions for pressure ulcer prevention after the resident's readmission. The only interventions listed were general measures such as gentle handling, observation of skin during ADLs, and weekly skin assessments. No new interventions were added after the resident developed a sacral pressure ulcer, a right heel pressure ulcer, and a left hip pressure ulcer. Additionally, no further Braden Scale assessments were completed after the change in condition, and there was no documentation system in place for staff to record repositioning. Observations confirmed that the resident was consistently found lying on his back in bed with heels not elevated, despite the use of a low air loss mattress. Interviews with nursing staff revealed that the resident required frequent repositioning and heel elevation, but these interventions were not reflected in the care plan or documented in the medical record. The lack of care plan updates and documentation contributed to the failure to implement appropriate pressure ulcer prevention measures.
Failure to Implement Pressure Ulcer Prevention Measures After Resident Readmission
Penalty
Summary
A deficiency occurred when a resident at risk for pressure ulcers did not have appropriate preventative measures in place following readmission from the hospital. The resident, who had multiple medical diagnoses including rib and vertebral fractures, prostate cancer, diabetes, DVT, and pneumonia, experienced a significant decline in mobility and cognition after hospitalization. Despite these changes, the care plan was not updated to reflect the increased risk, and no new interventions were added after the resident developed three pressure ulcers. Observations over several days showed the resident consistently lying in bed on his back without his heels elevated, despite staff interviews indicating that heel elevation was required. The resident had a low air loss mattress, but other preventative measures, such as regular repositioning and documentation of these interventions, were lacking. Staff interviews confirmed that the resident was largely bedbound and required substantial assistance, but there was no system in place for documenting repositioning, and the Braden Scale for pressure ulcer risk was not reassessed after the resident's condition changed. Medical record reviews revealed that the resident developed a sacral pressure ulcer, a right heel pressure ulcer, and a left hip pressure ulcer after readmission. Progress notes documented the emergence and progression of these wounds, as well as the treatments applied. The Director of Nursing confirmed that there was no facility policy on the prevention of pressure ulcers, further contributing to the lack of consistent preventative care for the resident.
Failure to Provide Routine Podiatry Services for At-Risk Residents
Penalty
Summary
The facility failed to arrange and provide appropriate podiatry services for two residents identified as being at risk and in need of specialized foot care. One resident, with a history of anxiety, depression, and difficulty walking, had previously received podiatry care for long, thickened, and painful toenails, with recommendations for ongoing routine debridement and antifungal treatment. Despite a documented need for follow-up podiatry appointments, there was no evidence in the medical record that these follow-up visits occurred. The resident's care plan indicated a need for assistance with grooming and nail care, but there was no documentation of continued podiatry involvement as recommended. Another resident, diagnosed with Type 2 Diabetes Mellitus with diabetic polyneuropathy and nail dystrophy, reported that his toenails were extremely long and sometimes painful, and that it had been some time since anyone had addressed them. Although this resident had previously received podiatry care with recommendations for routine follow-up, there was no evidence of ongoing podiatry services. Facility staff interviews confirmed that diabetic residents should be seen by podiatry, but neither of the two residents were listed on the facility's podiatry roster, and the Social Services Director acknowledged that there had not been a podiatry provider in the facility for some time.
Failure to Maintain and Store Respiratory Equipment Appropriately
Penalty
Summary
The facility failed to maintain and store respiratory equipment appropriately for a resident with a tracheostomy. Observations revealed that the resident's oxygen concentrator was dirty, with dried particles and a sticky surface, and the air filter was covered in white dust. The suction tubing was outdated, and the Yankauer suction tip was not stored in a plastic bag as required. These findings were confirmed during multiple observations and interviews with staff, who acknowledged that the equipment should have been cleaned and supplies changed according to facility policy and physician orders. The resident involved had significant medical needs, including anoxic brain damage, chronic respiratory failure, a gastrostomy, and a tracheostomy. Physician orders specified that oxygen was to be administered via trach mask with humidified air, and that respiratory supplies and equipment were to be changed regularly, with the concentrator filter cleaned weekly. Despite these orders and facility policy, the required cleaning and maintenance were not performed, resulting in the presence of soiled and improperly stored respiratory equipment.
Failure to Follow Infection Control Protocols for PPE, Hand Hygiene, and Equipment Cleaning
Penalty
Summary
Staff failed to follow infection prevention and control protocols as outlined in the facility's policies on Personal Protective Equipment (PPE) and Hand Hygiene. Two CNAs did not wear gowns or perform hand hygiene before, between, or after glove changes while providing personal care to a resident on Enhanced Barrier Precautions (EBP) due to an indwelling urinary catheter and pressure ulcers. During the care, gloves were changed multiple times without hand hygiene, and clean gloves were donned without sanitizing hands. The CNAs also touched various surfaces in the resident's environment without changing gloves or performing hand hygiene, and left the room without sanitizing their hands. A wound care RN also failed to perform hand hygiene before, between, and after glove changes during a dressing change for another resident. Additionally, two Certified Medication Aides did not sanitize a wrist blood pressure cuff between uses on different residents. Interviews with staff and leadership confirmed that infection control procedures were not followed as per facility policy, despite recent training.
Failure to Maintain Confidentiality of Resident Information
Penalty
Summary
The facility failed to ensure the confidentiality of personal and medical records for two residents. During an observation, it was noted that medication cards containing resident information were left unattended on top of the medication cart in the 400-hall. These cards were exposed and accessible to residents, staff, and visitors walking in the hall. The medication cards included sensitive information such as the resident's name, room number, physician name, and prescribed medication. This was in direct violation of the facility's policies on Resident Rights and Confidentiality of Personal and Medical Records, which mandate that personal and medical information should not be left unattended or viewable by unauthorized persons. During interviews, an LPN confirmed that the medication cards were inappropriately left unattended and demonstrated the correct procedure for disposing of them, which involves tearing off the top of the card containing resident information and placing it in the cart for proper disposal. The Administrator also confirmed that the expectation was for the nurse to tear off the top of the medication card and dispose of it appropriately to maintain the residents' privacy. This incident highlights a failure in adhering to the facility's policies and procedures regarding the confidentiality of resident information.
Failure to Follow Grievance Procedures
Penalty
Summary
The facility failed to follow its grievance procedures for a resident who was moderately cognitively impaired, as evidenced by a BIMS score of 10 out of 15. The resident's representative filed a grievance citing concerns about late medication administration, a dirty environment, a broken toilet seat, and the resident not being changed timely. The facility's policy required prompt efforts to resolve grievances and to provide a written decision to the resident or representative, but these steps were not completed. The Concern Form lacked documentation of follow-up actions, dates, and whether the individual was satisfied with the resolution. Interviews with staff revealed inconsistencies and a lack of clear communication regarding the grievance process, with the Social Services Director and Regional Nurse unable to recall specific details or confirm resolution steps taken. The Administrator acknowledged meeting with the family and addressing the medication issue but did not provide an explanation for the incomplete Concern Form. The Social Services Director mentioned logging the grievance for tracking but could not confirm if a resolution was reached. The Regional Nurse, who was previously the interim DON, stated she would typically write a response and pass it to the Social Services Director but did not remember the details of her involvement in this case. This lack of documentation and follow-up indicates a failure to adhere to the facility's grievance policy, resulting in the resident's concerns not being adequately addressed or resolved in a timely manner.
Failure to Maintain Dressing for Stage IV Sacral Ulcer
Penalty
Summary
The facility failed to ensure that a resident with a stage IV sacral pressure ulcer had a dressing maintained, leaving the wound exposed to urine and feces. The resident, who had diagnoses including type two diabetes with hyperglycemia and morbid obesity, was observed without a dressing on the sacral ulcer during a wound care observation. The facility's policy required that dressings be replaced if they became soiled or dislodged, but this was not adhered to in this case. The Wound Care Nurse confirmed that the dressing was missing and stated that nursing staff should have either replaced it or notified her if it had fallen off during care. Interviews with the Assistant Director of Nursing, Certified Nurse Aides, and the Administrator revealed that the staff were expected to notify a nurse if a dressing became soiled or dislodged. However, the Certified Nurse Aides were unaware that the dressing was missing and had not informed the nurse. The failure to maintain the dressing as per the facility's policy and the lack of communication among staff led to the deficiency in care for the resident's pressure ulcer.
Incomplete and Inaccurate Clinical Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate documentation for three residents. For Resident 3, the electronic medical records indicated that gabapentin was not documented as administered on multiple occasions in March and April 2024, with no corresponding nursing notes to explain the omissions. The Regional Nurse confirmed that the missing documentation should have been recorded accurately. Resident 3 was admitted with diagnoses including chronic pain, left hand contracture, and gastrostomy status, and had a BIMS score indicating moderate cognitive impairment. For Resident 1, there was no documentation of the resident's intake on several dates in March 2024. Resident 1 was admitted with diagnoses including necrotizing fasciitis, cystitis, and acute respiratory failure with hypoxia. For Resident 4, there was missing documentation for personal hygiene, bladder elimination, and the amount eaten on various dates in January and March 2024. The Administrator confirmed the missing documentation and stated that the expectation was for care provided to be documented appropriately. Resident 4 was admitted with diagnoses including chronic kidney disease, type two diabetes, and congestive heart failure.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Augusta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Richmond, Llc | 0.6 mi | ★★★★★ | 0 | 0 |
| Harrington Park Health And Rehabilitation | 1.2 mi | ★★★★★ | 8 | 0 |
| Place At Martinez, The | 1.5 mi | ★★★★★ | 17 | 0 |
| Pavilion At Brandon Wilde | 3.1 mi | ★★★★★ | 9 | 0 |
| Stevens Park Health And Rehabilitation | 3.5 mi | ★★★★★ | 0 | 0 |
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