Augusta Center for Health & Rehabilitation, LLC

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that a resident was free of accidents/hazards for a resident who had rolled out of bed during personal care resulting in a fracture for 1 of 3 residents reviewed for falls. (Resident #1).

Inspectors wroteBased on observations and interviews, the facility failed to adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and sanitary conditions for 3 of 3 units ([NAME], Penobscot and Kennebec Units) and a common area for 1 of 1 environmental tour (2/5/26).

Inspectors wroteBased on record review and interview, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 5 of 7 residents reviewed for care planning (Residents #3, #6, #7, #9, and #24).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure medications, including treatments, were stored properly by failing to obtain physician orders for medications located at a resident's bedside for 2 of 20 sampled residents (Residents #64, #9). In addition, the facility lacked evidence of consistent monitoring of medication storage room refrigerator temperatures to ensure proper medication and vaccine storage temperatures for 5 of 7 months reviewed.

Inspectors wroteBased on observation and interview, the facility failed to ensure the confidentiality of protected health information when resident identifiable assignment sheets and a monthly weight documentation sheet were left unattended in the solarium, an area accessible to residents and visitors, on 1 of 4 days of survey.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice in the area of nutrition and wound care for 2 of 20 sampled residents (Residents #6, #9).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide adaptive utensils for 1 of 3 residents reviewed for nutrition (Resident #6).

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a wall and the floor; failed to ensure foods were labeled and dated in a reach-in freezer; and failed to ensure kitchen staff with facial hair wore facial protection for 1 of 1 kitchen tour for 1 of 1 day of survey (2/1/26).

Inspectors wroteBased on observation, interviews, and Centers for Disease Control and Prevention (CDC) guidance, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to transporting soiled linens and disinfecting a soiled surface during a wound dressing observation for 1 of 3 residents reviewed for wounds (Resident #9).

Inspectors wroteBased on record review and interview, the facility failed to ensure that the resident's medical record included documentation that indicated that the resident or resident representative accepted a COVID-19 vaccine that the resident received for 1 of 5 residents reviewed for immunizations (Resident #24).

Inspectors wroteBased on observations and interviews, the facility failed to adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and sanitary conditions for 2 of 3 units ([NAME] Unit, and Kennebec Unit) for 1 of 1 environmental tour (11/19/24).

Inspectors wroteBased on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a grease trap, a baseboard heater register and the floor. Additionally, the facility failed to ensure foods were sealed, labeled and dated in a reach-in freezer and in a walk-in refrigerator for 1 of 1 kitchen tour for 1 of 1 day of survey (11/17/24).

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were treated in a dignified manner when staff failed to respond and attend to a resident's request for incontinence care during meal service. (Resident #40 [R40] and R41)

Inspectors wroteBased on record review and interviews, the facility failed to complete neurological assessments for 1 of 1 resident reviewed for fall with major injury (Resident #27 [R27]).

Inspectors wroteBased on record review, observation and interviews, the facility failed to provide the proper adaptive equipment to a resident during a meal service for 1 of 6 observed meals for Resident #35 [R35] who was involved in an incident on 11/6/24.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide respiratory care according to physician orders for 1 of 1 sampled residents (Resident #7 [R7]).

Inspectors wroteBased on observation and interview, the facility failed to adequately date open medications and properly dispose of expired medications, according to manufacturer specifications for two inhalers in 2 of 3 medication carts ([NAME] Unit, and Penobscot Unit) observed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a clinical record contained complete and accurate information for 1 of 1 residents reviewed for falls (Resident #27 [R27]).

Inspectors wroteBased on observations and interviews, the facility failed to promote care for residents in a manner that maintains each resident's dignity and respect when staff spoke and acted rudely to residents in their care for 2 of 2 residents reviewed (Resident #43 and Resident #33).

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable interior for the 3 of 3 units ( Penobscot, [NAME] and Kennebec) and a nurse's station for 1 of 1 facility tours (5/30/24).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that 2 of 3 residents reviewed with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASRR) evaluation and determination (Resident #33 and Resident #35).

Inspectors wroteBased on interviews and record reviews, the facility failed to provide services to maintain and/or improve residents highest level of ambulation and Active Range of Motion (AROM), the facility failed to provide Restorative services as outlined in the resident's restorative therapy program care planned for 2 of 2 sampled residents (Resident #43 and Resident #21,).

Inspectors wroteBased on observations, record reviews and interviews, the facility failed provide respiratory care consistent with professional standards of practice by failing to ensure that respiratory equipment was clean, failed to follow physician orders, and failed to date and label oxygen tubing for 5 of 5 sampled residents. (Resident #43, Resident #23, Resident #10, Resident #19, and Resident #160)

Inspectors wroteBased on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a ceiling vent, a food disposal unit, the dish machine, and a food mixer; failed to ensure facial hair protection was worn; and failed to ensure glasses were not wet stacked for 1 of 1 kitchen tour.

Inspectors wroteBased on record review and interviews, the facility failed to notify the resident and/or resident representative in writing for the reason of a transfer/discharge from the facility, for 1 of 2 hospital transfers (2/22/24) for Resident #36. In addition, the facility failed to notify the Ombudsman of the February transfer/discharge for Resident #36.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and/or the resident's representative in writing of a bed hold notice after a transfer/admission to an acute care hospital, for 1 of 2 hospital transfers (2/22/24) for Resident #36.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician orders for sliding scale insulin were followed for 1 of 4 residents reviewed (Resident #155).

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure nutrition and hydration parameters were met to maintain sufficient hydration and health for 2 of 2 residents reviewed for nutrition and hydration (Resident #11 and Resident #18).

Inspectors wroteBased on record review and interviews, the facility failed to ensure that physician's orders were followed for 1 of 5 sampled residents (Resident #2).

Inspectors wroteBased on observation and interview, the facility failed to transport soiled linens in a sanitary manner on 1 of 3 units. ([NAME] unit)