Augusta Health and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility did not provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections with the potential to affect all 37 residents.-Registered Nurse (RN) E did not perform glove change/hand hygiene appropriately during wound care to R10.-Laundry Aide (LA) G transported clean linens throughout the building uncovered.

Inspectors wroteBased on observations, interview and record review, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional practice. This had the potential to affect 4 of 4 residents: (R6, R10, and R25) for proper storage of insulin, (R15) for nebulizer solution storage, and the potential to affect all 28 residents residing on the C-D wing for use of bisacodyl suppositories, tuberculin vaccine, and influenza vaccine.

Inspectors wroteBased on observation, interview and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of all drugs to meet the needs of each resident. This was observed for 1 of 6 residents (R31) observed during medication administration. Registered Nurse (RN) I did not administer the correct dose of medication to a R31.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure the resident can use the assistive devices when consuming meals and snacks for 1 of 1 resident reviewed (R6).-R6 did not receive divided plate, setup, and straws with lids per the care plan.

Inspectors wroteBased on interview and record review, the facility did not ensure the resident environment remained as free of accidents as possible for 2 of 4 residents (R29, R4) reviewed for accidents. The facility did not complete a thorough investigation of falls for root cause and implement interventions to prevent further falls. R29 had a fall on 12/19/24 that resulted in a left femur fracture and surgical repair. This example is cited at actual harm. The facility did not complete a thorough investigation of falls to determine staff following plan of care, root cause, monitor for trends, and re-assess interventions to prevent further accidents for R4. This is evidenced by: The facility Fall Evaluation, Intervention, and Reporting policy updated/reviewed 10/10/24 states: [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure the facility's garbage was properly stored in the dumpster. The failure had the potential to promote a breeding ground for pests and rodents affecting all 39 residents within the facility.

Inspectors wroteBased on interviews and record reviews, the facility did not consult with a physician as indicated by ordered parameters with a significant weight change for 2 of 2 residents (R) R4 and R14. This is evidenced by: The facility policy titled, Notification of Changes Policy, last updated on 01/10/25, states: It is the policy of this facility that changes in a resident's condition or treatment, are immediately shared with the resident and or the resident representative, according to their authority, and reported to the attending or delegate. Example 1 R4 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, chronic kidney disease and diabetes mellitus type 2. R4's annual Minimum Data Set (MDS), dated [DATE], Section K, indicated R4's weight of 193# and no indication of a physician-prescribed weight loss or weight gain regimen. [...]

Inspectors wroteBased on record review and interview, the facility did not accurately code the Minimum Data Set (MDS) assessments for 3 of 12 residents (R) reviewed. (R4, R29 and R32). The facility did not accurately code R4, R29 and R32's MDS assessment with correct number of falls that occurred during the referenced time frame. This is evidenced by: Example 1 R4 was admitted on [DATE] and current diagnoses included, in part, type 2 diabetes mellitus with diabetic nephropathy, epilepsy, age-related osteoporosis, peripheral vascular disease, congestive heart failure, malignant neuroendocrine tumors, malignant neoplasm of liver, chronic kidney disease stage 3b and depression. Review of MDS dated [DATE] an annual assessment documented Brief Interview of Mental Status (BIMS) score of 15, indicating R4 is cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections from the catheter. For 1 of 1 resident (R32) reviewed with a Foley catheter. R32's Foley catheter was changed on a routine monthly basis without clinical indications and not following professional standards of practice. This is evidenced by: The Centers for Disease Control and Prevention (CDC), Healthcare Infection Control Practices Advisory Committee (HICPAC), Guideline for prevention of catheter-associated urinary tract infections 2009, read in part, E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. [...]

Inspectors wroteBased on record review and interviews, the facility did not ensure acceptable parameters of nutritional status, such as usual body weight or desirable body weight range by recognizing or assessing a significant weight loss for 1 of 1 resident (R14) reviewed. This is evidenced by: The facility policy titled: Notification of Changes Policy, last updated on 01/10/25, states in part, Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and their resident's physician, to ensure best outcomes of care for the resident. R14 was admitted to facility on 12/03/24 and has a Brief Interview for Mental Status (BIMS) of 11 out of 15, indicating mildly impaired cognitive level. R14's admission assessment Minimum Data Set (MDS) with target date of 12/09/24, Section K: [...]

Inspectors wroteBased on observation and interview, the facility did not ensure staff followed procedures for the accurate administration of medication for 1 of 1 resident (R25). Staff administered multiple medications at once via gastrostomy tube. This is evidenced by: Facility policy titled, Gastrostomy Intermittent Tube Feeding/Medication, with no date states in part: Policy: Licensed nursing staff will feed/provide medication through a resident's gastrostomy tube following orders of the physician. Procedure: 12. Pour 1 ounce (30 cc) of room temperature water into the syringe barrel to check for patency. If water flows freely, the gastrostomy tube is patent. 13. Administer medications at this time, as ordered by the physician. - Administer one medication at a time. - After each medication, flush the gastrostomy tube with a small amount of water. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure controlled drugs were stored in separately locked, permanently affixed compartments for 1 of 2 med storage units. Observation of a controlled medication stored in the unlocked refrigerator located in the medication room.

Inspectors wroteBased on interview and record review, the facility did not ensure residents received routine dental services for 1 of 1 resident (R25) reviewed. This is evidenced by: State Operations Manual Appendix PP states in part: The facility must assist residents in obtaining routine and 24-hour emergency dental care. The facility must provide or obtain from an outside resource, in accordance with §483.70(f) of this part, the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan. R25 was admitted to the facility 04/07/23 with pertinent diagnoses of hemiplegia and hemiparesis (immobility/weakness) following cerebral vascular accident (stroke), malignant neoplasm of brain (tumor), dementia, dysphagia, and depression. [...]

Inspectors wroteBased on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 5 care observations for residents (R) (R13, R192, R6). Staff did not complete appropriate hand hygiene while providing care for R13's personal cares. Staff did not complete appropriate hand hygiene while providing care for R192. Staff used a contaminated scissors and used dirty gauze to complete wound care for R6. This is evidenced by: Facility policy titled, Handwashing/Hand Hygiene, with a revised date of 10/23 stated in part: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for Hand Hygiene 1. Hand hygiene is indicated: f. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure the comprehensive plan of care was implemented by staff for 2 of the 5 residents (R5 and R4) reviewed. R5's care plan was not followed to receive ambulation assistance to meals. R4's care plan was not followed to lie down for 1-2 hours between meals. This is evidenced by: Example 1: R5 was admitted to the facility on [DATE], with diagnoses including malignant neoplasm of bladder, hypertension, anemia, and anxiety disorder. R5's minimum data set (MDS) assessment, completed on 06/01/24, confirmed R5 scored 15 during a brief interview for mental status (BIMS), indicating impaired cognition. R5 requires set-up assistance with eating and oral hygiene. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not prepare, distribute, and serve food in a manner that prevents foodborne illness to all 38 residents (R) in the facility.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program to prevent Legionella, or provide hand hygiene to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect 38 of 38 residents (R) residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to or ensure the reporting of a reasonable suspicion of a crime in accordance with section 1105B of the Act to law enforcement, or report an allegation of abuse immediately but not later than 2 hours after the allegation is made, to the state agency when a family member to resident abuse allegation was made. This occurred for 1 of 1 incidents (R) R8 reviewed.

Inspectors wroteBased on record review and interview, the facility did not complete a thorough investigation of an allegation of sexual abuse for 1 of 1 resident (R8).

Inspectors wroteBased on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan addressing medical and nursing needs for residents with pressure wounds and non-pressure related skin disturbances. This occurred for 1 of 4 residents (R) reviewed. (R17).

Inspectors wroteBased on observations, interviews and record reviews, the facility did not provide wound care and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being for 1 of 3 residents (R187) reviewed.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 1 resident (R) observed receiving insulin. (R17)

Inspectors wroteBased on observation, interview and record review, the facility did not always serve food that was palatable and served at the right temperature for 1 of 6 sampled residents (R), R26. This is evidenced by: R26 was admitted to the facility on [DATE] with diagnoses that include, in part, hypertension, pain, and a history of falls. On 12/18/23 at 11:00 AM, Surveyor interviewed R26 who stated she is very unhappy with the food. R26 stated the food at the facility tastes bland, and it is always cold. The facility seems to have to take my food back and reheat it often. R26 stated she has complained to staff about this, but it has not improved. Record review indicates R26 has an order for a regular diet. R26's Minimum Data Set (MDS) assessment dated [DATE] showed R26 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points. This indicates R26 is cognitively intact. [...]

Inspectors wroteBased on staff interview and record review, the facility did not notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing for 2 of 4 residents (R) (R9 and R33) reviewed.