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 Lakepoint Augusta, Llc during CMS and state inspections, most recent first.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment presented risks that were not mitigated, and supervision was not sufficient to ensure resident safety.
The facility failed to maintain and reconcile drug records for controlled substances, with missing staff signatures on Narcotic Count Shift Verification forms. The east hall form lacked 63 signatures, and the west hall form lacked 30 signatures over a period. Staff were required to count narcotics at shift changes and sign the form to verify the count, as per facility policy.
The facility failed to submit accurate weekend licensed nurse staffing data to CMS for August 2024. Administrative Nurses worked weekends but their hours were not recorded in the PBJ report due to their salaried status. The facility lacked a policy for PBJ report completion, leading to inaccurate submissions.
The facility failed to implement Enhanced Barrier Precautions for two residents with infection risks, did not maintain sanitary conditions for a resident's CPAP machine, and failed to ensure proper urinary catheter care. Additionally, a resident's pet was not up-to-date with vaccinations, highlighting multiple infection control deficiencies.
The facility failed to complete accurate MDS for three residents, leading to deficiencies in care planning. A resident with a neurocognitive disorder had incomplete Behavioral Symptoms and Psychosocial Well-Being CAAs. Another resident with dementia had an incomplete Behavioral Symptoms CAA, and a third resident with multiple diagnoses had several CAAs triggered but not completed. These omissions resulted in a lack of comprehensive assessments necessary for individualized care planning.
The facility failed to accurately complete MDS documentation for four residents, leading to deficiencies. One resident's MDS did not reflect antipsychotic medication use, another's did not document rejection of care despite medication refusal, a third's inaccurately recorded hospice care status, and the fourth's did not reflect CPAP machine use. These inaccuracies were confirmed through observations, interviews, and record reviews.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. One resident with a history of suicide ideation lacked personalized interventions in their care plan. Another resident with renal failure did not have a detailed fluid restriction plan. A third resident using a CPAP machine had no care plan instructions for its use and maintenance, resulting in unclean equipment and staff confusion over responsibilities.
A facility failed to monitor a dialysis resident's fluid restriction, leading to excessive fluid intake. The resident, with renal failure, had a 1500 ml fluid limit, but staff were unaware or inconsistent in tracking intake. The care plan lacked specific instructions, and staff interviews revealed communication gaps. The facility policy required accurate fluid recording, which was not followed.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment posed risks that were not addressed, and supervision was insufficient to prevent potential incidents. No further details about the specific hazards, the nature of the supervision, or the residents involved are provided in the report.
Failure to Maintain and Reconcile Controlled Drug Records
Penalty
Summary
The facility failed to establish a system to maintain and reconcile drug records for controlled substances, as evidenced by missing staff signatures on the Narcotic Count Shift Verification forms. Specifically, the east hall form lacked 63 staff signatures, and the west hall form lacked 30 staff signatures from October 1 through October 27, 2024. Certified Medication Aide (CMA) T and Administrative Nurse D confirmed that staff were required to count narcotics with the oncoming and off-going nurse or CMA at the beginning and end of their shifts, and both were expected to sign the form to verify the count was correct. The facility's policy, revised in November 2022, mandated that nursing staff count the controlled medication inventory at the end of each shift to reconcile the inventory count, with both the incoming and outgoing nurses making the count together.
Inaccurate Weekend Staffing Reporting in PBJ
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the month of August 2024. Specifically, the facility did not accurately report weekend licensed nurse staffing in their Payroll Base Journal (PBJ) Staffing Data Report. This discrepancy was identified during a review of the PBJ report, which showed that the hours worked by Administrative Nurses D and F on weekends were not included because they were salaried employees and did not clock in. Interviews with facility staff revealed that Administrative Nurses D and F worked during weekends in August, but their hours were not recorded in the PBJ report. Administrative Staff A acknowledged the issue and mentioned the need to find a way for these nurses to clock in to ensure accurate reporting. Additionally, the facility lacked a policy for completing PBJ reports, contributing to the inaccurate submission of staffing information to CMS.
Infection Control Deficiencies in EBP, CPAP, and Catheter Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, R3 and R54, who were at risk of spreading infections due to their medical conditions. R3 had a chronic abscess with a history of Methicillin-Resistant Staphylococcus Aureus (MRSA) and required specific infection prevention measures, including Hibiclens showers. However, during wound care, staff did not wear gowns or follow EBP protocols. Similarly, R54, who had a dialysis port and a history of infections, was not provided with EBP during care, despite the facility's policy indicating the necessity of such precautions for residents with indwelling medical devices. The facility also failed to maintain sanitary conditions for R50's CPAP machine. The CPAP face mask was observed to be unclean, with a flaky, whitish substance inside, and there was confusion among staff regarding who was responsible for cleaning it. The facility's policy required the CPAP face mask to be cleaned with warm water and dried between uses, but this was not consistently done, leading to potential infection risks. Additionally, the facility did not ensure proper urinary catheter care for R56, whose catheter bag and tubing were observed resting on the floor, contrary to the facility's policy. The catheter care plan required the bag and tubing to be kept off the floor to prevent contamination. Furthermore, R19's dog was not up-to-date with its rabies vaccination, and the facility lacked a policy to monitor pet vaccinations, posing an additional infection control issue.
Incomplete MDS and CAA Documentation for Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Sets (MDS) for three residents, leading to deficiencies in the assessment and care planning process. Resident 15, diagnosed with a neurocognitive disorder with behavioral disturbances, had an incomplete Behavioral Symptoms and Psychosocial Well-Being Care Area Assessment (CAA) on their admission MDS. Despite receiving antipsychotic, antianxiety, and antidepressant medications, the necessary analysis of findings was missing, which is crucial for developing an individualized care plan. Resident 56, who has dementia, also had an incomplete Behavioral Symptoms CAA on their admission MDS. The resident exhibited verbal behaviors directed towards others, yet the CAA lacked the required analysis of findings. This omission occurred despite the resident being on antidepressant medication and having a care plan that instructed staff to monitor for potential verbal aggression and medication side effects. Resident 7, with multiple diagnoses including major depressive disorder and bipolar disorder, had several CAAs triggered but not completed on their admission MDS. These included assessments for urinary incontinence, falls, nutritional status, psychotropic drug use, and pain. The resident was cognitively intact and reported frequent moderate pain, yet the necessary analysis of findings was not conducted. The facility's failure to complete these CAAs as required by the Resident Assessment Instrument Manual resulted in a lack of comprehensive assessments necessary for individualized care planning.
Inaccurate MDS Documentation for Four Residents
Penalty
Summary
The facility failed to complete accurate assessments for four residents, leading to deficiencies in the Minimum Data Set (MDS) documentation. Resident 7's MDS did not accurately reflect the use of antipsychotic medication, despite physician orders indicating the prescription of Lurasidone Hydrochloric for bipolar disorder. Observations and interviews confirmed the resident's cognitive status and medication use, yet the MDS lacked documentation of antipsychotic medication use during the assessment period. Resident 33's MDS failed to document the behavior of rejection of care, despite evidence of medication refusal. The resident, diagnosed with depression, anxiety, and unspecified dementia, refused several medications over a period, as noted in the Medication Administration Record. Interviews with staff confirmed the resident's refusal of medications and treatments, yet the MDS did not reflect this behavior. Resident 5's MDS inaccurately documented hospice care status, despite a physician's order for hospice care due to multiple sclerosis. The resident's care plan indicated hospice care, but the MDS assessments did not reflect this status. Similarly, Resident 50's MDS inaccurately documented the use of a CPAP machine, despite physician orders and staff interviews confirming its use. Observations noted the presence of the CPAP machine in the resident's room, yet the MDS did not accurately reflect its use during the assessment period.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. One resident, with a history of suicide ideation, did not have a care plan that included personalized interventions for their mental health concerns. Despite being monitored for adverse reactions to antidepressant therapy, the care plan lacked specific strategies to address the resident's previous suicide ideation upon their return to the facility. Another resident, diagnosed with renal failure and undergoing dialysis, did not have a personalized fluid restriction care plan. Although the care plan instructed staff to offer small frequent feedings and maintain a fluid restriction, it lacked detailed instructions on fluid allocation per shift and the resident's preferences. This oversight was confirmed by the administrative nurse, highlighting the absence of a tailored approach to the resident's fluid management needs. The third resident, diagnosed with obstructive sleep apnea, did not have a care plan that included instructions for the use and maintenance of their CPAP machine. Observations revealed the CPAP face mask was left uncovered and uncleaned, with staff unsure of who was responsible for its maintenance. The administrative nurse acknowledged that the CPAP machine should have been included in the resident's care plan, indicating a failure to ensure the resident's highest practicable well-being.
Failure to Monitor Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to ensure accurate monitoring of a resident's fluid restriction as ordered by the physician. The resident, who was diagnosed with renal failure and required dialysis, had a fluid restriction of 1500 milliliters per 24 hours. However, the care plan lacked specific instructions for staff regarding the allocation of fluids per shift and the resident's preferences. Observations revealed that the resident consumed more fluids than allowed, including drinking from large cups and consuming soup broth, which was not adequately tracked by the staff. Interviews with various staff members indicated a lack of awareness and inconsistent documentation of the resident's fluid intake. The facility's policy on encouraging and restricting fluids required staff to follow specific instructions and accurately record fluid intake, which was not adhered to in this case. Interviews with the staff, including a Certified Medication Aide, Dietary Staff, and Licensed Nurse, revealed gaps in communication and understanding of the resident's fluid restriction. The Administrative Nurse confirmed that the care plan did not reflect the resident's preferences and that all staff should have been aware of the fluid restriction. This deficiency highlights a failure in ensuring all staff were informed and compliant with the resident's fluid management needs.
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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) |
|---|---|---|---|---|
| Lakepoint El Dorado, Llc | 9.1 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Andover | 9.5 mi | ★★★★★ | 4 | 4 |
| El Dorado Care And Rehab | 11.7 mi | ★★★★★ | 22 | 0 |
| Avita Health And Rehab At Reeds Cove | 12 mi | ★★★★★ | 11 | 0 |
| Advena Living At Fountainview | 13.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.