Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pruitthealth - Richmond, Llc during CMS and state inspections, most recent first.
A resident with cognitive and physical impairments was unable to reliably use the call light system due to difficulty pressing the button and vision deficits. After a new call light system was installed, no assessment was conducted to ensure the resident could use the device, and previously used touch pads were found incompatible. Staff confirmed the resident's inability to activate the call light independently, and the lack of assessment following the system change contributed to the deficiency.
The facility experienced delays in completing and transmitting Minimum Data Set (MDS) assessments for thirteen out of thirty-four residents. The delays were linked to a transition to a new company, which left resident records in the previous company's electronic systems, and a shortage of staff. Interviews with the MDS Coordinator and RN MDS Coordinator revealed that Admission MDS assessments for residents admitted in April 2024 were not completed due to time constraints. Additionally, an incomplete Admission MDS assessment for one resident indicated a lack of interview to determine activity preferences, as required for accurate assessment.
The facility did not ensure proper labeling and dating of food items in the dry storage room, with opened containers missing labels and dates. Additionally, kitchen equipment used for food preparation was found to be unclean, with substances observed inside the ovens. These issues had the potential to impact 77 out of 79 residents receiving an oral diet from the kitchen. Observations on multiple occasions confirmed these deficiencies. Interviews with the Dietary Manager and Administrator revealed that staff were expected to follow food policies on labeling, dating, and cleaning, but turnover in the Dietary Department posed challenges in maintaining compliance.
The facility experienced a One-Star Staffing Rating and low weekend staffing metrics due to inaccurate reporting of direct care staffing data to CMS for Q1 FY 2024. The issue arose from a management change where salaried employees did not consistently clock in and out, and agency staff did not use the facility's time clock system until February.
The facility did not provide evidence of a process for periodic review of antibiotic prescribing practices and failed to document follow-up measures for three months of infection control data. This deficiency could hinder the development of an action plan for infection concerns by the Infection Control Committee. Facility policies showed gaps in monitoring and documenting antibiotic stewardship activities, including tracking infection and antibiotic usage patterns, antibiotic resistance trends, and the appropriateness of antibiotic prescriptions. The Antibiotic Stewardship Log was underutilized, and there was a lack of documentation of surveillance data and communication with physicians regarding residents receiving antibiotics that did not meet criteria for true infections. Interviews with the Director of Health Services and Administrator revealed reliance on the McGeer infection Report from the electronic medical records system, but discrepancies were found in categorizing residents receiving antibiotics. The Director of Health Services acknowledged the lack of monitoring and surveillance of the program and the incorrect inclusion of residents not meeting criteria for true infections in monthly infection rate calculations.
The facility failed to ensure a medication cart on Richmond Hall was locked and secured when not in use. An LPN left the cart unlocked and unattended with a cup of pills on top and the EHR open, visible to anyone passing by. The LPN admitted to being nervous due to the presence of state surveyors. The DON confirmed that medication carts should always be locked when unattended and that nurses should cover or log out of the EHR when not in use.
A resident with muscle weakness and hemiparesis expressed a preference to get up between 6:00 am and 6:30 am, but the facility failed to honor this preference due to staffing issues. Despite being listed on the 11-7 get-up list, the resident was often not gotten up until after 10:00 am, leading to dissatisfaction and complaints. Staff interviews confirmed the issue, and the resident's concerns were known to the Social Service Director and Administrator, but no effective action was taken.
The facility failed to maintain a safe, clean, and comfortable environment on Richmond Hall, as evidenced by a persistent urine odor. Staff interviews and observations confirmed that residents' dirty laundry was stored in their rooms for up to a week before being laundered, contributing to the odor. Despite deep cleaning efforts, the issue persisted.
The facility failed to develop a baseline care plan for one resident and did not address essential care needs or include a discharge care plan for another. The facility's policies require baseline care plans to be initiated within 24 hours and completed within 48 hours of admission, but these requirements were not met.
The facility failed to develop comprehensive care plans for two residents. One resident did not have a discharge care plan despite multiple diagnoses, and another resident lacked care plans for nutrition, behaviors, and psychotropic medication use. These deficiencies were confirmed by the MDS Coordinator.
The facility failed to revise the care plan for a resident with a pressure ulcer. Despite the resident having an unstageable pressure ulcer to the sacrum, the care plan was not updated to reflect this condition. Interviews confirmed that the interdisciplinary team did not fulfill their responsibility to update the care plan as required.
The facility failed to reconcile and document pre-discharge medications with post-discharge medications for a resident, R126, and did not provide documentation that the medications were transferred at discharge. The resident reported not receiving all medications, and staff interviews confirmed the lack of proper procedure and documentation.
The facility failed to provide an individualized activities program for a resident with multiple psychiatric diagnoses. Despite repeated requests for a coloring book and crayons documented in her psychiatry notes, there was no evidence that these requests were fulfilled. The resident spent most of her time lying in bed, expressing dissatisfaction with the activities provided. The facility had been without an Activities Director for two months, and the Administrator acknowledged that the resident's specific requests had been overlooked.
A resident's medications were crushed and combined by an RN without a physician's order, contrary to the facility's policy and the physician's instructions to take the medications whole. The DON confirmed that medications should be administered as per physician's orders, and any resident preference should be followed up with a physician to obtain the necessary order.
The facility failed to ensure puree recipes were followed, resulting in improperly prepared food for eight residents on a puree diet. Dietary Cook CC did not measure the liquid added to the hamburger meat, leading to a thinned and watery consistency.
Failure to Provide Accessible Call Device for Resident with Impairments
Penalty
Summary
A deficiency occurred when a resident with non-traumatic brain dysfunction, non-Alzheimer's dementia, and depression was not provided with a call device that accommodated their needs. The resident, who had one-sided impairment and was dependent for eating and hygiene, was documented as being at risk for falls and having a vision deficit. The care plan required the call light to be kept within reach. However, multiple observations and interviews revealed the resident was unable to reliably activate the call light due to numbness in their hands and difficulty pressing the button. The call light did not activate consistently, and the resident could not visually confirm if it was working due to their vision deficit. Staff interviews indicated that after the installation of a new call light system, no formal assessment was conducted to ensure each resident could use the new devices. The touch pad call lights previously used were incompatible with the new system, and the facility had not completed call device assessments with the new system. The maintenance director and nursing staff confirmed the lack of compatibility and assessment, and the administrator acknowledged that he was not present during the installation to verify resident accommodation.
Delayed Completion and Transmission of MDS Assessments Due to Transition and Staffing Issues
Penalty
Summary
The facility failed to ensure timely completion and transmission of Minimum Data Set (MDS) assessments for multiple residents, as identified during the survey. Thirteen out of thirty-four residents had at least one or more MDS assessments completed late, with examples including Quarterly Assessments and Admission MDS assessments not being completed or transmitted within the required timeframes. Staff interviews revealed that the delay in assessments was attributed to a transition to a new company in October 2023, resulting in resident records being in the previous company's electronic systems, coupled with a shortage of staff hindering timely completion and transmission of assessments. Furthermore, interviews with the MDS Coordinator and RN MDS Coordinator highlighted instances where Admission MDS assessments for residents admitted in April 2024 were not completed or transmitted, with reasons cited such as lack of time to complete assessments. The facility's policy emphasized the importance of accurate MDS assessments reflecting the acuity and medical status of each resident, yet deficiencies in completing assessments within required timeframes were evident. Additionally, a specific case involving Resident R22 highlighted incomplete sections in the Admission MDS assessment, indicating a lack of interview with the resident to determine activity preferences, as required for accurate assessment completion.
Labeling and Sanitation Issues in Food Storage and Kitchen Equipment
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in the dry storage room, with opened food containers lacking labels and dates. Additionally, kitchen equipment used for food preparation was found to be unclean and unsanitary, with substances observed inside the ovens. The deficiency had the potential to impact 77 out of 79 residents receiving an oral diet from the kitchen. Observations on multiple occasions revealed the lack of labeling and dating on food containers, as well as unclean kitchen equipment. Interviews with the Dietary Manager and Administrator indicated expectations for staff to follow food policies on labeling, dating, and cleaning kitchen equipment. The Administrator mentioned previous in-services with dietary staff on these topics, highlighting turnover in the Dietary Department as a challenge in ensuring compliance with food safety protocols.
Inaccurate Staffing Data Reporting Leads to One-Star Rating
Penalty
Summary
The facility failed to accurately report direct care staffing data to CMS for the first quarter of Fiscal Year 2024, resulting in a One-Star Staffing Rating and Excessively Low Weekend Staffing metrics being triggered. The deficiency stemmed from a recent change in management, where salaried employees did not consistently clock in and out, and agency staff did not use the facility's time clock system until February of that year.
Deficiency in Antibiotic Stewardship and Infection Control Monitoring
Penalty
Summary
The facility failed to provide evidence of a process for periodic review of antibiotic prescribing practices and to document follow-up measures in response to the data for three months of infection control data reviewed. The deficiency had the potential to prevent the development of an action plan related to identified infection concerns within the facility by the Infection Control Committee. The review of facility policies revealed gaps in monitoring and documenting antibiotic stewardship activities, including tracking infection and antibiotic usage patterns, antibiotic resistance trends, and appropriateness of antibiotic prescriptions. The Antibiotic Stewardship Log was found to be underutilized, and there was a lack of documentation of surveillance data and communication with physicians regarding residents receiving antibiotics that did not meet criteria for true infections. During interviews with the Director of Health Services and Administrator, it was revealed that the facility relied on the McGeer infection Report from the electronic medical records system to determine if infections met criteria, but there was a discrepancy in how residents receiving antibiotics were categorized. The Director of Health Services acknowledged the lack of monitoring and surveillance of the program, as well as the incorrect inclusion of residents not meeting criteria for true infections in the monthly infection rate calculations.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that one of two medication carts on the Richmond Hall was locked and secured when not in use. An observation revealed that the cart was left unlocked and unattended with a plastic 30 ml medicine cup containing pills on top of the cart, and the Electronic Health Record (EHR) was open with resident information visible on the computer screen. The Licensed Practical Nurse (LPN) responsible for the cart confirmed that he left it unlocked and unattended because he was nervous due to the presence of state surveyors. The cart remained unsecured for four minutes. The Director of Nursing (DON) stated that medication carts should always be locked when unattended and that nurses are expected to administer medication immediately after it is pulled and to lock the cart before walking away. Additionally, the DON expects nurses to cover the computer screen or log out when not in use.
Failure to Honor Resident's Preference for Scheduled Times to Get Out of Bed
Penalty
Summary
The facility failed to honor a resident's preference for scheduled times to be gotten out of bed, which had the potential to affect the resident's psycho-social well-being. The resident, who had diagnoses including generalized muscle weakness, right hand contracture, and hemiplegia and hemiparesis following a cerebral infarction, expressed a preference to get up between 6:00 am and 6:30 am. Despite being listed on the facility's 11-7 get-up list, the resident reported that his preference was not honored, attributing this to staffing issues. Observations confirmed that the resident was often not gotten up until after 10:00 am, leading to dissatisfaction and complaints from the resident. Interviews with staff, including a CNA and LPN, corroborated the resident's claims, indicating that the night shift staff often failed to get the resident up due to staffing shortages. The Social Service Director and the Administrator were aware of the resident's preference and had spoken to the staff about it, but the issue persisted. The resident had also voiced his concerns during a resident council meeting, but no effective action had been taken to address the issue. The facility's failure to honor the resident's preference for getting up early in the morning was a clear deficiency in promoting and facilitating resident self-determination and choice.
Persistent Malodorous Smell on Richmond Hall
Penalty
Summary
The facility failed to ensure a safe, clean, and comfortable home-like environment on Richmond Hall, as evidenced by a persistent malodorous smell throughout the hall. Observations revealed a strong stale urine odor on multiple occasions, and staff interviews confirmed the presence of the odor. The Director of Health Services, Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistants, and the Administrator all acknowledged the odor but were unsure of its exact origin. The odor was noted to be different and more pronounced on Richmond Hall compared to other areas of the facility. The issue was attributed to the storage of residents' dirty laundry in hampers within their rooms, which were only collected and washed once a week due to limited laundry facilities. The facility's policy on Infection Control - Housekeeping Services, revised on 10/16/2023, mandates routine and consistent housekeeping to maintain an orderly, sanitary, and comfortable environment. However, the policy was not effectively implemented on Richmond Hall. The Housekeeping Supervisor and Laundry Aide confirmed that residents' dirty laundry remained in their rooms for up to a week before being laundered, contributing to the persistent odor. Despite deep cleaning the carpet, the issue persisted, indicating that the primary source of the odor was the unbagged dirty laundry stored in residents' rooms.
Failure to Develop Baseline and Discharge Care Plans
Penalty
Summary
The facility failed to develop a baseline care plan that included essential components based on the resident's stay for two residents. Specifically, the facility did not ensure that one resident had a baseline care plan developed after admission, and another resident's care plan did not address essential care needs or include a discharge care plan. The facility's policies require that a baseline care plan be initiated within 24 hours and completed within 48 hours of admission, and that discharge care plans be established at the time of admission and updated as needed. However, these requirements were not met for the two residents in question. One resident was admitted with multiple diagnoses, including chronic obstructive pulmonary disease (COPD), anxiety disorder, and chronic respiratory failure (CRF). The resident's baseline care plan was incomplete and did not capture the overall care needs, including the use of psychotropic medications. The MDS Coordinator confirmed that the baseline care plan was missing essential components such as communication, activities of daily living (ADL), and pain management. Another resident was admitted and later discharged to the hospital without a baseline care plan being developed by the facility staff. The MDS Coordinator stated that baseline care plans are the responsibility of the admitting nurse and should be completed within 48 hours of admission, but this was not done for the resident in question.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the specific needs of two residents. For one resident, admitted with multiple diagnoses including a fracture, pulmonary disease, hypertension, diabetes, and chronic kidney disease, the facility did not create a discharge care plan. This omission was confirmed by the MDS Coordinator, who acknowledged that the discharge care plan should have been implemented at the time of admission but was overlooked due to the responsibilities being managed by remote MDS staff. Another resident, admitted with diagnoses including pseudobulbar affect, mood disorder, vascular dementia, and protein-calorie malnutrition, did not have a comprehensive care plan addressing nutritional status, behaviors, or the use of psychotropic medications. This deficiency was confirmed by the MDS Coordinator, who acknowledged the absence of the necessary care plans for this resident.
Failure to Update Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident with a pressure ulcer. The resident was admitted with diagnoses including Parkinson's disease, myasthenia gravis, anorexia, and a pressure ulcer of an unspecified site. The comprehensive care plan, last revised on 4/26/2024, indicated the resident was at risk for skin breakdown due to incontinence, impaired mobility, and impaired joint range of motion, with a deep tissue pressure injury to the left heel. However, the care plan did not reflect the actual condition of the resident, who had an unstageable pressure ulcer to the sacrum with an onset date of 3/14/2024. Interviews with the Minimum Data Set (MDS) Coordinators confirmed that it is the responsibility of the interdisciplinary team to update care plans. Despite this, the resident's care plan was not updated to reflect the actual wound condition. This failure to update the care plan as required by the facility's policy and the OBRA MDS schedule led to the deficiency identified in the report.
Failure to Reconcile and Document Medications at Discharge
Penalty
Summary
The facility failed to reconcile all pre-discharge medications with the resident's post-discharge medications for one resident, R126. The facility also did not provide documentation that R126's medications were transferred with her at the time of discharge. R126, who had a BIMS score indicating little to no cognitive impairment, reported that the facility nurse did not give her all her medications and informed her that she would receive them by mail in two weeks. A review of the resident's physician orders revealed multiple medications prescribed, but there was no evidence in the Electronic Medical Record (EMR) that these medications were reconciled or given to the resident at discharge. The Regional Consultant confirmed the lack of documentation, and the Register Nurse (RN) involved could not recall if she provided the medications, nor did she reconcile or sign off on them. The RN also reported not receiving education on the proper procedure for medication reconciliation and documentation at discharge. The Director of Health Services (DHS) outlined the correct procedure for discharging residents, which includes reviewing medications with the Medical Director, dating and timing medication packages, and providing education to the resident or responsible party. However, this procedure was not followed in the case of R126. The DHS confirmed that the nurse should have documented the medication reconciliation and provided the medications to the resident, but this did not occur. The failure to follow the discharge planning policy and properly document and reconcile medications led to the deficiency identified in the report.
Failure to Provide Individualized Activities Program
Penalty
Summary
The facility failed to provide an individualized activities program for one resident (R22) as required by their policy. R22, who was admitted with multiple psychiatric diagnoses including generalized anxiety disorder, major depressive disorder, and schizoaffective disorder, had repeatedly requested a coloring book and crayons as part of her recreational activities. Despite these requests being documented in her psychiatry follow-up notes over several months, there was no evidence in her electronic medical records that an Activities Assessment had been completed or that her requests had been fulfilled. Observations and interviews revealed that R22 spent most of her time lying in bed, with her television being her only source of activity when it was working. She expressed dissatisfaction with the activities provided and confirmed that staff had not offered her the requested coloring book and crayons. The facility had been without an Activities Director for about two months, during which time the Administrator, who is a certified activities director, and an Activities Assistant were responsible for providing activities. However, the Activities Assistant had not completed an activities preference interview with R22 and was unaware of her specific requests. The Social Services Director and the Administrator also confirmed that they were not aware of the recommendations for a coloring book and crayons documented in R22's psychiatry notes. The Administrator acknowledged that these recommendations had been overlooked and that there were no activity notes or assessments completed for R22 in the electronic medical records. During multiple observations and interviews, R22 was consistently found lying in bed without the requested coloring book and crayons. She reported that staff had not offered her any one-to-one activities or encouraged her to participate in group activities. The Administrator confirmed that activity notes and assessments were documented on paper and kept in her office, but these were not provided before the survey exit. The lack of individualized activities and failure to address R22's specific requests highlight a significant deficiency in the facility's activities program.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to administer medication to a resident (R22) as prescribed by the physician. Specifically, the resident's medications were supposed to be taken whole, but the Registered Nurse (RN) crushed and combined multiple medications without a physician's order. The medications included Allopurinol, Amlodipine, Aspirin, Bisacodyl, Buspar, Colace, Gabapentin, Klonopin, Metoprolol Tartrate, Singulair, Oxcarbazepine, Oxybutynin Chloride, Sodium Chloride, Effexor, Pravastatin, and Cranberry Extract. The RN then mixed the crushed medications with vanilla pudding before administering them to the resident. This action was contrary to the facility's policy and the physician's orders, which required medications to be taken whole unless otherwise indicated by a physician's order. The RN stated that the resident preferred their medications crushed, but no such order was present in the medical record. The Director of Nursing (DON) confirmed that medications should be administered as per physician's orders and that any preference by the resident to have medications crushed should be followed up with a physician to obtain the necessary order. The RN involved had been working at the facility for about six months and had received in-service training on medication administration during orientation. This incident highlights a failure to adhere to prescribed medication administration protocols, leading to a significant medication error for the resident involved.
Failure to Follow Puree Recipe Guidelines
Penalty
Summary
The facility failed to ensure puree recipes were followed to conserve the nutritive value of food items served to eight residents receiving a puree consistency diet. During an observation, Dietary Cook CC was seen preparing food for these residents. She placed 10 pieces of hamburger meat into a food processor and pureed it for approximately one minute. She then left the area to get beef gravy and beef base from the cooler, returning with a half-filled container of a liquid substance. The Surveyor did not observe the actual measurement of the liquid added, and the resulting puree hamburger meat appeared thinned and watery, not meeting the required puree consistency. Interviews with Dietary Cook CC, the Administrator, and the Dietary Manager revealed that the dietary staff were expected to follow the recipes. However, the provided recipe for pureed hamburgers did not specify the amount of meat or liquid needed, leading to inconsistency in the preparation. The Dietary Cook claimed to have followed the recipe, but the observation and the resulting product indicated otherwise, highlighting a failure in adhering to the recipe guidelines for pureed diets.
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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.
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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) |
|---|---|---|---|---|
| Harborview Health Center Of Augusta | 0.6 mi | ★★★★★ | 0 | 0 |
| Harrington Park Health And Rehabilitation | 1.8 mi | ★★★★★ | 8 | 0 |
| Place At Martinez, The | 2.1 mi | ★★★★★ | 17 | 0 |
| Pavilion At Brandon Wilde | 3.4 mi | ★★★★★ | 9 | 0 |
| Pruitthealth - Evans, Llc | 3.9 mi | ★★★★★ | 0 | 0 |
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