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 Augusta Health And Rehabilitation during CMS and state inspections, most recent first.
Two residents experienced repeated falls due to the facility's failure to investigate root causes and update care plans with effective interventions. One resident suffered a femur fracture requiring surgery, while the other had multiple falls related to wheelchair brake issues and improper footwear. The facility lacked a fall investigation process, contributing to these deficiencies.
The facility failed to properly dispose of garbage, leading to an overflowing dumpster and garbage bags on the ground during an outbreak. The use of Styrofoam containers increased waste volume, and staff were unclear about arranging additional garbage pickups. The NHA acknowledged the issue but emphasized resident safety as a priority.
The facility failed to notify a physician of significant weight changes for two residents, despite having orders to do so. One resident experienced a significant weight gain, while another had a substantial weight loss, yet neither case was reported to the physician or dietician as required by the facility's policy.
A resident with a Foley catheter had it changed monthly without clinical indications, contrary to CDC and HICPAC guidelines. The facility's policy and hospice orders required routine changes, but no medical rationale was documented. The DON acknowledged the deficiency and noted the Medical Director would review the policy.
A resident experienced a significant weight loss of 22.4 pounds over two months, which was not documented or addressed by the facility. Despite being at nutritional risk due to multiple diagnoses, the facility failed to notify the physician or dietician, as required by their policy. The resident expressed satisfaction with the weight loss, but the lack of assessment and notification represents a deficiency in care practices.
A facility failed to follow proper medication administration procedures for a resident with a gastrostomy tube. An LPN was observed instructing another LPN to crush and combine six medications, administering them all at once, contrary to the policy of administering each medication separately with a flush in between. The DON confirmed this was not the expected practice and could potentially harm the resident.
A facility failed to store controlled drugs in a locked compartment as required. A surveyor observed an unlocked refrigerator in the medication room containing an open bottle of Lorazepam for a resident. An LPN acknowledged the refrigerator should have been locked, explaining that a new refrigerator was installed without a lock. The DON confirmed awareness of the issue and mentioned that a lock had been ordered but not yet installed.
A resident with severe cognitive impairment and multiple medical conditions did not receive routine dental services as required. The resident's medical record lacked dental service notes, and interviews revealed that the resident's APOA had reportedly declined dental services, but this was not documented.
A facility failed to maintain proper infection control practices, as observed in multiple instances of inadequate hand hygiene and the use of contaminated equipment during resident care. A CNA did not change gloves or perform hand hygiene after providing incontinence care to a resident with a history of stroke and dementia. The same CNA also failed to perform hand hygiene between glove changes while assisting another resident prone to urinary tract infections. Additionally, an LPN used contaminated scissors and dirty gauze during wound care on a resident's leg.
The facility inaccurately coded MDS assessments for three residents, leading to discrepancies in fall documentation. One resident was incorrectly noted as having multiple falls with major injury, another was documented with a fall that did not occur, and a third resident's significant fall resulting in a fracture was not recorded. The DON confirmed these errors, and a consulting company was engaged to assist with MDS coding.
The facility failed to follow the care plans for two residents, resulting in unmet care needs. One resident did not receive the required ambulation assistance to meals, while another was not laid down between meals as per their care plan. Observations and staff interviews revealed a lack of documentation and adherence to the care plans.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, leading to multiple falls and injuries. Resident R29, who had severe cognitive impairment and mobility issues, experienced numerous falls without thorough investigations or updates to the care plan. Despite having a history of falls, the facility did not conduct root cause analyses or implement effective interventions, resulting in a fall that caused a left femur fracture requiring surgical repair. Resident R4, who was cognitively intact but had multiple health conditions, also experienced several falls. The facility did not consistently investigate the root causes of these falls or ensure that care plan interventions were followed. R4's falls were often related to issues with wheelchair brakes and the absence of proper footwear, yet the facility failed to address these issues adequately or update the care plan with new interventions. The Director of Nursing acknowledged the lack of a fall investigation process and the need for a plan of correction. The facility's failure to investigate falls, determine root causes, and implement effective interventions contributed to repeated falls and injuries for both residents, highlighting significant deficiencies in the facility's fall prevention and management practices.
Improper Garbage Disposal During Outbreak
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed by the surveyor during an inspection. The dumpster was found overflowing with black garbage bags, with additional bags piled on the ground around it. This situation was noted during a facility outbreak, where Styrofoam containers were being used instead of plates, contributing to the increased volume of waste. The Dietary Director indicated that garbage collection occurred twice a week, but was unsure if additional pickups could be arranged when the dumpster overflowed. Further interviews with the Director of Nursing and the Nursing Home Administrator revealed a lack of clarity and coordination regarding the management of waste during outbreaks. The Director of Nursing also confirmed the regular garbage pickup schedule but was uncertain about arranging additional pickups. The Nursing Home Administrator acknowledged the possibility of acquiring an additional dumpster at an extra cost but emphasized the priority of resident safety by using Styrofoam containers. The surveyor highlighted the importance of maintaining a clean dumpster area to prevent pest infestations.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to consult with a physician as required by ordered parameters for significant weight changes in two residents, R4 and R14. R4, who was admitted with diagnoses including congestive heart failure and chronic kidney disease, had orders to notify the physician if there was a weight gain of more than 3 pounds in one day or 5 pounds in one week. Despite a significant weight gain of over 7 pounds in one day and 4 pounds the next, the facility did not notify the physician as required. The Director of Nursing (DON) confirmed that the expectation was to follow the orders and contact the physician, but this was not done. Similarly, R14, who was at nutritional risk due to multiple diagnoses, experienced a weight loss of 22.4 pounds over two months without any documentation, assessments, or notification to the physician or dietician. The DON confirmed that there was no documentation related to identifying the weight loss and that neither the physician nor the dietician was notified of the weight change. This lack of communication and failure to follow the facility's policy on notifying changes in a resident's condition contributed to the deficiency.
Inappropriate Routine Catheter Change Without Clinical Indication
Penalty
Summary
The facility failed to ensure that a resident with an indwelling Foley catheter received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections. The deficiency was identified for a resident who had their Foley catheter changed on a routine monthly basis without clinical indications, contrary to the guidelines set by the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC). These guidelines recommend changing catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised, rather than at routine, fixed intervals. The resident in question was admitted with multiple diagnoses, including malignant neoplasm of the bladder and other chronic conditions. Despite having no concerns or infections related to the catheter, the facility's policy and hospice orders dictated a monthly change of the catheter, which was not supported by a medical rationale or clinical indications. The Director of Nursing acknowledged the lack of a medical rationale for the monthly catheter changes and indicated that the Medical Director would be conducting further research before any policy changes would be made.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure acceptable parameters of nutritional status for a resident, identified as R14, by not recognizing or assessing a significant weight loss. R14 was admitted to the facility with a Brief Interview for Mental Status (BIMS) score indicating a mildly impaired cognitive level and had a care plan noting nutritional risk due to multiple diagnoses, including hypertensive heart disease and chronic kidney disease. Despite a care plan goal to avoid significant weight changes, R14 experienced a weight loss of 22.4 pounds over two months, which was not documented or addressed by the facility. The Director of Nursing (DON) confirmed that there was no documentation or notification to the physician or dietician regarding R14's significant weight loss. The facility's policy on Notification of Changes requires staff to identify and report changes in a resident's status to ensure the best outcomes, but this was not followed in R14's case. The resident expressed satisfaction with the weight loss and reported a good appetite, but the lack of assessment and notification represents a deficiency in the facility's care practices.
Improper Medication Administration via Gastrostomy Tube
Penalty
Summary
The facility failed to ensure proper medication administration procedures were followed for a resident receiving medications via a gastrostomy tube. The facility's policy requires that medications be administered one at a time, with the gastrostomy tube flushed between each medication. However, during an observation, a Licensed Practical Nurse (LPN) was seen instructing another LPN to crush and combine six medications into a single cup, mix them with water, and administer them all at once through the gastrostomy tube. This practice deviated from the facility's policy and was confirmed by the LPN as standard practice, despite the policy's clear instructions to administer medications individually. The Director of Nursing (DON) was interviewed and confirmed that the expected practice is to administer each medication separately with a flush in between, as per the facility's policy. The DON acknowledged that administering all medications at once was not the expected practice and could potentially cause harm to the resident. The incident involved one resident, identified as R25, who was receiving multiple medications through a gastrostomy tube, and the observation highlighted a significant deviation from the established medication administration procedures.
Controlled Drug Storage Deficiency
Penalty
Summary
The facility failed to ensure that controlled drugs were stored in separately locked, permanently affixed compartments, as required by their policy. During an observation, a surveyor found an unlocked refrigerator in the medication room containing an open 30ml bottle of Lorazepam intended for a resident. The Licensed Practical Nurse (LPN) present acknowledged that the refrigerator should have been locked but explained that a new refrigerator had been installed recently, and the lock had not yet been replaced. The Director of Nursing (DON) confirmed awareness of the issue and mentioned that a lock had been ordered but not yet installed.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure that a resident received routine dental services as required. The resident, admitted on 04/07/23, had significant medical conditions including hemiplegia, hemiparesis, a malignant brain tumor, dementia, dysphagia, and depression. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment and a dependency on assistance for oral hygiene. Upon review, the surveyor found no dental service notes in the resident's medical record. Interviews revealed that the resident's Activated Power of Attorney (APOA) stated that no dental care had been provided since admission. The Medical Records (MR) staff confirmed that no dental services had been provided and mentioned that the APOA had declined dental services, although there was no documentation to support this declination.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and the use of contaminated equipment during resident care. In one instance, a Certified Nursing Assistant (CNA) provided incontinence care to a resident with a history of cerebral vascular accident, hemiplegia, obesity, and dementia, without changing gloves or performing hand hygiene after cleaning the peri-area. This failure to follow proper hand hygiene protocols was acknowledged by the CNA during an interview with the surveyor. Another incident involved the same CNA conducting morning care for a resident prone to urinary tract infections. The CNA repeatedly changed gloves without performing hand hygiene in between, while assisting the resident with transfers, toileting, and personal hygiene tasks. This lack of adherence to hand hygiene protocols was confirmed by the CNA during an interview with the surveyor, who noted the absence of handwashing or sanitizer use after glove changes. Additionally, a Licensed Practical Nurse (LPN) was observed performing wound care on a resident's left lower leg using contaminated scissors and dirty gauze. The LPN used the same scissors to cut both the old bandage and the new sterile dressings without sanitizing them in between. Furthermore, the LPN used the same gauze to clean both the non-open and open areas of the wound, which was acknowledged as improper practice by the LPN during the surveyor's interview.
Inaccurate MDS Coding for Falls
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in the documentation of falls. Resident 4, who has a range of diagnoses including type 2 diabetes mellitus and chronic kidney disease, was incorrectly documented as having two or more falls with major injury on their MDS. However, a review of their fall history revealed only one fall with no injury and one fall with a minor injury during the specified timeframe. Similarly, Resident 32, with diagnoses such as malignant neoplasm of the bladder and chronic obstructive pulmonary disease, was documented as having a fall with no injury, despite no falls occurring during the assessment period. The Director of Nursing (DON) confirmed the inaccuracies in the MDS coding for these residents. Resident 29, diagnosed with dementia and macular degeneration, was also affected by incorrect MDS coding. Their assessment failed to reflect a fall resulting in a left femur fracture and subsequent surgical repair, which occurred during the assessment period. The DON acknowledged the error but could not provide an explanation, as the MDS Coordinator was on vacation. These inaccuracies in MDS coding were identified during a survey, and the facility had engaged a consulting company to assist with MDS coding and training new staff starting in October.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement the comprehensive care plan for two residents, R5 and R4, as observed by surveyors. R5, who has diagnoses including malignant neoplasm of the bladder and anxiety disorder, was not provided with the required ambulation assistance to meals as per his care plan. Despite the care plan and physician orders specifying that R5 should be ambulated three times daily to meals with standby assistance, R5 reported not having walked in over ten days. Observations confirmed that R5 self-propelled in a wheelchair to meals, and staff interviews revealed a lack of documentation and execution of the ambulation plan. Similarly, R4, diagnosed with dementia and osteoarthritis of the hip, was not laid down for 1-2 hours between meals as outlined in the care plan. Observations showed R4 sitting in a wheelchair throughout the day without being laid down. Staff interviews indicated that R4 was kept up if humming and holding a stuffed cat, contrary to the care plan. The Director of Nursing was unable to provide a reason for the deviation from the care plan, and there was no documentation explaining why the care plan was not followed. These deficiencies highlight a failure in the facility's adherence to the care plans for R5 and R4, resulting in unmet care needs. The lack of proper documentation and communication among staff contributed to the non-compliance with the residents' care plans, as evidenced by the surveyor's observations and staff interviews.
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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.
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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) |
|---|---|---|---|---|
| Dove Healthcare - Osseo | 7.6 mi | ★★★★★ | 6 | 0 |
| Dove Healthcare - South Eau Claire | 17.6 mi | ★★★★★ | 0 | 0 |
| Oakwood Health Services | 17.9 mi | ★★★★★ | 14 | 0 |
| Grace Lutheran Communities - River Pines | 18 mi | ★★★★★ | 3 | 0 |
| Pigeon Falls Hcc | 18.7 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.