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 Lakepoint Augusta, Llc during CMS and state inspections, most recent first.
Medication administration errors exceeded the allowed rate, with multiple errors observed during med pass. An LN crushed and mixed a resident’s oral tablets, including simvastatin, for G-tube administration without an order to crush or combine the meds, and a CMA failed to offer a resident a rinse after administering a budesonide-formoterol inhaler as ordered. The EHR lacked orders for crushing/mixing and for an oral simvastatin tablet, and staff confirmed the missing orders.
A resident with severe cognitive impairment, dementia, and dependence for all ADLs was repeatedly observed reclined in a Broda chair at the dining table, often facing away from her table mate and with drinks placed out of reach while waiting for meal assistance. Staff later assisted her with breakfast and lunch, but observations showed she remained unattended in the dining room for extended periods before CNA assistance was provided, despite staff stating residents should not wait long for meal help.
Failure to ensure safe self-administration of medications for three residents. One resident with intact cognition, one resident with moderately impaired cognition, and one resident with intact cognition were observed with medication cups and pills at the bedside, but their EMRs lacked both a self-administration order and a safe self-medication assessment. Staff stated residents are evaluated for self-administration and then receive a physician order if safe, and the facility policy requires the interdisciplinary team to determine clinical appropriateness and safety.
A resident with pain, hx of falls, overactive bladder, severely impaired cognition, limited BLE ROM, and dependence for toileting, bathing, and transfers had a care plan directing staff to keep the call light within reach. During observation, the resident was sitting in a high-back wheelchair watching TV, but the call light was pinned to the wall out of reach. Staff interviews confirmed call lights should be within the resident's reach when in the room.
A resident with TIA, stroke, quadriplegia, depression, and anxiety had intact cognition on MDS, but his code status was inconsistent across records: the care plan and hard chart listed him as full code while the EHR listed him as DNR and included a DNR order and signed DNR. An LN confirmed the mismatch and noted no DNR paperwork was in the EHR, while the resident stated he wanted to be DNR and had signed a DNR. Facility policy required advance directives to be maintained in the medical record and the care plan to match the resident’s documented preferences.
A resident’s PHI was left visible on an unlocked laptop on a medication cart parked outside the dining room, where the screen showed medications, DOB, allergy information, and code status to anyone passing by. Staff stated the screen should have been locked and the cart kept locked and free of visible personal information.
Financial Exploitation by Housekeeping Staff: A resident with moderate cognitive impairment and depression was coerced by a housekeeping employee into giving her $80 after repeated requests for money and claims of needing groceries. A CNA witnessed the interaction, and the resident later confirmed she gave the money because she felt bad for the employee.
Failure to document rationale for no GDR of psychotropic meds. A resident with anxiety, depression, and dementia had orders for duloxetine, quetiapine, and haloperidol, and the MDS showed severely impaired cognition. Pharmacy review requested documented rationale for GDR recommendations, but the prescriber marked no change without explaining why no GDR would be attempted. Observations showed the resident resting in bed with no combative behavior or resistance during care.
Failure to Provide Required Transfer Notifications: The facility did not provide written transfer notices to three residents or their representatives when they were transferred to the hospital. The records lacked evidence that the notices included resident rights, the transfer location, the reason for transfer, and LTCO information, and the hospital transfer log did not document the transfers. Staff also confirmed the LTCO was not notified, and no discharge policy was provided.
Unattended unlocked treatment cart with resident medications. An LPN left a treatment/med cart unlocked and unattended while entering a resident room, with the cart containing nebulized txs, topical meds, dressing supplies, and multiple insulin pens for several residents. The LPN stated the cart should never have been left unlocked and unattended, and the ADON stated the cart should be locked whenever staff walked away and resident information should not be visible to unauthorized persons.
Meals were not maintained at safe, appetizing temperatures for residents eating in their rooms. A CNA delivered a breakfast tray with food temperatures in the low 110s, and a resident stated the food arrives cold. Dietary staff reported the hot box should hold meals at 145 degrees F, but it was measured at 110 degrees F and could not be adjusted higher; the facility policy did not address palatable temperatures.
Failure to implement EBP was observed when a resident with a G-tube had no signage or readily available PPE, including gowns, and an LN provided meds via the tube wearing gloves but no gown. Staff interviews showed inconsistent understanding of when EBP and PPE were used, and the facility did not provide a policy for EBP or PPE practices.
Inaccurate Daily Nurse Staffing Sheet Posting: The facility failed to post accurate daily nurse staffing information, including the census. A staffing sheet posted behind the front desk listed a census of 71, while the census verified by Administrative Staff A was 67. The same outdated sheet remained posted the next day, and no current sheet was observed. Administrative Staff A stated the CSA updates the staffing sheets and that an incorrectly completed sheet would require education.
Inaccurate PBJ Staffing Submission: The facility failed to submit complete and accurate direct care staffing information through PBJ. CMS data for FY 2026 Q2 showed excessive low weekend staffing, but staffing sheets showed the same number of direct care staff worked on weekends and weekdays. Administrative Staff A confirmed the facility did not have low weekend staffing and stated the DON, ADON, and MDS Nurse worked weekends as needed.
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.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate below five percent. During observation, record review, and interview, 26 medication administrations were observed and 15 errors were identified, resulting in a medication error rate of 57.69%. One resident had multiple medication orders for administration via G-tube, including finasteride, fludrocortisone acetate, furosemide, gabapentin, metoprolol, midodrine, mirabegron oral suspension, oxybutynin, potassium chloride, simvastatin oral suspension, ProSource, probiotic, clopidogrel, and ferrous sulfate. The resident’s EHR lacked orders for medications to be crushed and/or mixed and lacked an order for an oral tablet for simvastatin. During observation, an LN crushed the resident’s oral tablet medications, including simvastatin, and mixed them with liquid medication before administering them via G-tube. The LN stated that all oral medication tablets were crushed and mixed with ProSource, potassium chloride, and mirabegron oral suspensions, and confirmed there was no current order to crush or combine the medications. In a separate observation, a CMA administered a budesonide-formoterol inhaler to another resident but did not offer or encourage the resident to rinse her mouth afterward as ordered. An administrative nurse stated that prior to crushing and/or mixing medications, an order should be obtained from the physician and the pharmacist should be consulted to ensure the medications could safely be mixed. The facility policy stated medications were to be administered safely and as prescribed, and that the medication administrator was to verify the right resident, right medication, right dosage, right time, and right method before giving the medication.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure Resident 22 was treated with respect and dignity while waiting to be assisted with meals. Resident 22 had diagnoses including cognitive communication deficit, senile degeneration of the brain, diabetes mellitus, and need for assistance with personal care. The Annual MDS dated 05/15/2026 documented a BIMS score of 3, indicating severely impaired cognition, and that she was dependent on staff assistance with all activities of daily living. Her CAA dated 05/28/2026 documented she was at risk for a self-care deficit related to dementia, and her care plan stated she needed assistance with all decision making, enjoyed talking with her roommate and staff, and had little activity involvement related to immobility. During observations, Resident 22 was repeatedly found reclined in her Broda chair at the end of the dining room table, often facing away from her table mate, with a cup or glass of fluid placed out of reach. On 06/22/2026 at 08:18 AM, she sat reclined with a cup of fluid out of reach. On 06/23/2026 at 07:41 AM, she again sat reclined with a glass of fluid out of reach and her back to her table mate; her table mate left at 08:17 AM, leaving her alone until CNA P assisted her with breakfast at 08:23 AM. Later that day, she sat with her back to her table mate while a staff member placed a cup of fluid out of her reach at 11:42 AM, and CNA P did not assist her with lunch until 12:04 PM. Staff interviews reflected expectations that residents should not wait long for meal assistance, with CNA Q stating a resident should not wait more than five to 10 minutes and LN G stating a resident should never sit in the dining room more than 20 to 30 minutes before staff assisted with meals.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure safe and appropriate self-administration of medications for three residents: R23, R37, and R45. R23’s EMR showed a BIMS score of 15 on the admission MDS, indicating intact cognition, but the Orders tab did not contain an order for self-administration of medications and the Assessment tab did not contain an assessment for safe self-medication administration. On 06/22/2026 at 08:11 AM, R23 was observed lying on her bed with a paper medication cup containing pills on the bedside table. R37’s Quarterly MDS documented a BIMS score of 12, indicating moderately impaired cognition, and his EMR also lacked both an order for self-administration of medications and an assessment for safe self-medication administration. On 06/22/2026 at 08:54 AM, R37 was observed lying on his bed with a paper medication cup and a pill on the bedside table. R45’s Significant Change MDS documented a BIMS score of 15, but his EMR likewise lacked an order for self-administration of medications and lacked an assessment for safe self-medication administration. On 06/22/2026 at 08:54 AM, R45 was observed lying on his bed with the head of his elevated bedside table next to his bed and a paper medication cup with pills on the table. On 06/24/2026, an LN stated residents can administer their own medications if evaluated as safe by BIMS score and then ordered by the physician, while an Administrative Nurse stated residents are assessed for self-administration in the EMR and then receive a physician order if safe. The facility’s Self-Administration of Medications policy stated residents have the right to self-administer medications if the interdisciplinary team determines it is clinically appropriate and safe.
Call light left out of resident's reach
Penalty
Summary
The facility failed to ensure Resident 13's call light was within reach so the resident could call for staff assistance. Resident 13's EMR documented diagnoses of pain, history of falls, overactive bladder, and need for assistance with personal care. The Quarterly MDS dated 05/15/2025 documented a BIMS score of 7, indicating severely impaired cognition, along with limited ROM in both lower extremities and dependence on staff for toileting, bathing, and transfers. The resident's CAA dated 12/01/2025 documented a need for assistance with ADLs, and the care plan directed staff to ensure the call light was within reach and encourage use as needed. During observation on 06/22/2026 at 09:51 AM, Resident 13 was seated in a high back wheelchair in the room watching TV, and the call light was pinned to the wall between the TV and dresser, out of reach. Staff interviews supported that call lights should be placed within the resident's reach when the resident is in the room, including a CNA who stated call lights should be placed on the person or clipped to the bed within reach, an LN who stated call lights should always be within the resident's reach, and an Administrative Nurse who stated call lights should be within the resident's reach if the resident was in the room. The facility's Accommodation of Needs policy stated the environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being.
Advance Directive and Code Status Documentation Not Aligned
Penalty
Summary
The facility failed to verify that Resident 7’s advance directive was properly documented in both the hard chart and the care plan. Resident 7 had diagnoses including TIA, cerebral infarction, chronic pain due to trauma, quadriplegia, major depressive disorder, and anxiety disorder. His Annual MDS documented a BIMS score of 15, indicating intact cognition. The care plan dated 05/23/2025 listed him as full code, while the EHR home screen listed his code status as DNR. The EHR also contained a physician order for DNR dated 05/22/2026 and an admission section entry showing a signed DNR dated 05/14/2026, uploaded on 06/23/2026 by Administrative Nurse D. Review of the hard chart kept behind the nurse’s station found a blue sheet stating full code, and observation of the chart revealed a blue dot on the spine of the chart. Licensed Nurse I stated the blue dot indicated the resident was full code and that there was a DNR or blue sheet in the front of the chart, while also confirming the EHR listed the resident as DNR and that no DNR paperwork was in the EHR. The resident stated he wished to be a DNR and reported that he had signed a DNR. Administrative Nurse D stated the resident’s code status should be accurately uploaded in the EHR and the paper chart should reflect the EHR, and that the chart and EHR should be corrected and updated regularly. The facility policy required copies of executed advance directives to be maintained in the medical record and the plan of care to be consistent with documented treatment preferences and/or advance directives.
Resident PHI Left Visible on Unlocked Medication Cart Computer
Penalty
Summary
The facility failed to keep Resident 23’s protected health information private when a medication cart was parked in the main dining room hallway with a laptop computer left unlocked and open on top of the cart. During the initial tour, Resident 23’s PHI was visible to anyone passing by the cart and included the resident’s medications, date of birth, allergy information, and code status. A CMA stated the computer screen should have been locked, a LN stated the medication cart should be locked with no personal information visible and no medication left on the cart when staff walked away, and an Administrative Nurse stated the cart should be clean and locked with no personal health information left on the computer for others to see. The facility’s Confidentiality of Information and Personal Privacy policy stated that resident confidentiality and personal privacy would be protected and safeguarded.
Financial Exploitation of Resident by Housekeeping Employee
Penalty
Summary
The facility failed to protect a resident from the wrongful use of her money when a housekeeping employee coerced her into giving up $80. The resident had diagnoses of major depressive disorder, pain, and insomnia, and her records documented moderate cognitive impairment with a BIMS score of 12 and care plan interventions for impaired cognitive function and depression. A certified medication aide witnessed the housekeeper ask the resident to borrow money, heard the resident direct the housekeeper to her wallet, and saw the housekeeper take money after the resident agreed. The resident later stated that the housekeeper told her she needed money for groceries and kept asking until the resident gave her $80. The facility investigation documented that the housekeeper had previously sold the resident handmade jewelry and then asked her for money, including additional money for food and groceries. Staff reported the concern as possible financial exploitation, and the resident confirmed she felt bad for the housekeeper and gave her the money. The report also documented that the employee was terminated, a police report was filed, and the resident was reimbursed, but the deficiency was based on the facility's failure to ensure the resident remained free from exploitation when the employee obtained her money.
Failure to Document Rationale for No GDR of Psychotropic Medications
Penalty
Summary
The facility failed to perform a gradual dose reduction (GDR) or provide a physician rationale for not attempting a GDR for a resident’s psychotropic medications. The resident had diagnoses of generalized anxiety disorder, major depressive disorder, and dementia, and the Significant Change MDS documented a BIMS score of 00, indicating severely impaired cognition. The care plan identified psychotropic use, including quetiapine and haldol, related to a mild neurocognitive disorder, and directed staff to consult pharmacy and consider dosage reduction when clinically appropriate at least quarterly. The resident’s EMR showed orders for duloxetine 60 mg daily and quetiapine 50 mg twice daily, and the pharmacy consultant documented a recommendation for review. A note to the attending physician/prescriber listed haloperidol, quetiapine, and duloxetine as psychotropic medications due for review and requested documented rationale for GDR recommendations, but the physician marked no change and did not provide a rationale for not attempting GDR. Observations showed the resident lying in bed and appearing to sleep, and staff repositioned and changed the resident with no combative behavior or resistance observed. During interview, the Administrative Nurse stated the facility had asked for a rationale related to the consultant pharmacist recommendation but only had what was documented on the recommendation.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to ensure that Resident R12, Resident R37, and Resident R76, or their representatives, received written notification of transfer to the hospital that included the residents' rights, the transfer location, the reason for transfer, and the state ombudsman information as soon as practicable after transfer. Record review showed R12 had a Discharge MDS dated 04/10/2026 documenting an unplanned discharge to an acute hospital with return anticipated, and R37 had a Discharge MDS dated 04/27/2026 documenting an unplanned discharge to an acute hospital with return anticipated. In both records, there was no evidence that written transfer notification was provided, and the facility was unable to produce such documentation when asked. R76 was transferred to the hospital via EMS on 04/30/2026 at 02:15 PM for evaluation of symptoms, and the EMR also lacked evidence that written notification of the transfer was provided to R76 or her representative. Review of the facility's Monthly Transfer Log to Hospital for 02/01/2026 through 05/31/2026 did not include documentation of the transfers for R12, R37, or R76, and the LTCO was not notified of these transfers. On 06/24/2026, Administrative Staff A stated that the facility had not provided written notice to R12, R37, or R76, or their legal representatives, and stated that the social service department was responsible for the notification. The facility did not provide a discharge policy.
Unattended unlocked treatment cart with resident medications
Penalty
Summary
The facility failed to ensure that resident medications and biologicals were properly secured in locked storage. During observation on 06/22/2026 at 10:38 AM, LN G unlocked the treatment/nurse cart in the 100/200/300 hall and left it unattended while she went down the 200 hall and into a resident's room. The cart contained seven boxes of nebulized breathing treatments, three containers of Vick's vapor rub, tubes of icy hot muscle rub, several tubes of calmoseptine ointment, and dressing change supplies. The same cart also contained multiple insulin injector pens for several residents, including R3, R54, R46, R24, R52, R40, R63, R69, and R70. On 06/22/2026 at 10:45 AM, LN G stated that a medication or treatment cart should never have been left unlocked and unattended. On 06/24/2026 at 12:35 PM, Administrative Nurse D stated that whenever a nurse or medication aide walked away from the medication cart area or treatment cart, the cart should have been cleaned and locked and no resident information should have been readily available for viewing by unauthorized persons. The facility policy Medication Labeling and Storage, dated February 2023, stated that compartments containing medications and biologicals would be locked when not in use and that trays or carts used to transport such items would not be left unattended when open or otherwise potentially available to others.
Meals Served at Unsafe Temperatures
Penalty
Summary
The facility failed to ensure meals were served at safe and appetizing temperatures. On 06/23/2026 at 09:36 AM, a CNA delivered a breakfast meal to a room in the 100 hall, and the food temperatures were measured at 116 degrees F for the hashbrowns, 114 degrees F for the cheese omelet, and 115 degrees F for the oatmeal. On 06/22/2026 at 08:15 AM, a resident stated that the food arrives to his room cold. On 06/23/2026 at 09:40 AM, the CNA said she was not sure how hot the food was supposed to register, but it likely should have been hotter. Later that morning, Dietary BB stated that the standing warmer used to hold prepared meals for residents who eat in their rooms should be 145 degrees F, but the warmer was measured at 110 degrees F and could not be adjusted higher. The facility policy did not address palatable temperatures.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff did not follow Enhanced Barrier Precautions for a resident with a G-tube. During an observation on 06/23/2026 at 11:33 AM, there was no signage or readily available PPE, including gowns, for R6, who had a gastronomy tube. The observation further showed LN H donned gloves but no gown and administered the resident’s medications via the G-tube. LN H later verified that both a gown and gloves should have been worn for EBP. In interviews, CNA M stated that EBP and PPE would be used whenever a resident had an infection and also if the resident had a urinary catheter, while Administrative Nurse D stated EBP and PPE are used for any indwelling device and any open wound being treated. The facility did not provide a policy for EBP or PPE practices.
Inaccurate Daily Nurse Staffing Sheet Posting
Penalty
Summary
The facility failed to ensure the posted daily nurse staffing sheets included accurate information, including the daily census. During an observation on 06/22/2026 at 10:13 AM, the staffing sheet posted behind the front desk documented a census of 71, while Administrative Staff A verified during the initial entrance that the census was 67. During a later observation on 06/23/2026 at 11:05 AM, the same staffing sheet dated 06/22/2026 was still posted, and no sheet for 06/23/2026 was observed. During interview on 06/23/2026 at 02:19 PM, Administrative Staff A stated that the customer service associate updates the daily staffing sheets, that three CSAs were employed to ensure coverage every day, and that if a CSA called in, the administrator would be responsible for updating the sheet. He also stated that if the daily staffing sheet had not been filled out correctly, the CSA would need to be educated.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information through the Payroll-Based Journal (PBJ) system based on payroll and other verifiable and auditable data. The CMS PBJ Staffing Data Report for FY 2026 Quarter 2 showed excessive low weekend staffing, but review of the facility staffing sheets showed the same number of direct care staff worked on weekends and weekdays. During interview, Administrative Staff A verified the facility did not have low weekend staffing and stated that the DON, ADON, and MDS Nurse worked on weekends as needed. The facility policy titled Reporting Direct Care Staffing Information (Payroll Based Journal), revised August 2022, stated that direct care staffing information was reported electronically to CMS through the PBJ system.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 237 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lakepoint Augusta, Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.