Augusta Nursing and Rehabilitation

Inspectors wroteBased on observations, staff interview, and facility document review, it was determined that the facility staff failed to provide snacks at bedtime to diabetic residents and snacks to general residents for four of five residents in the survey sample, Residents #2, #5, #3 and #4.

Inspectors wroteBased on observations, resident/staff interview facility, document review and clinical record review, it was determined the facility staff failed to implement the care plan for two of five residents in the survey sample, Residents #2 and #5.

Inspectors wroteBased on clinical record review and staff interview, facility staff failed to provide ADL (activites of daily living) care for one of five residents in the survey sample, Resident #3.

Inspectors wroteBased on observations, staff interview and clinical record review, facility staff failed to provide ADL (activities of daily living) for dependent residents for two of five residents in the survey sample, Resident #4 and #1.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to prepare food in a sanitary manner in one of one facility kitchens.

Inspectors wroteBased on observations, staff interviews, resident interviews, clinical record review, and facility documentation review, the facility staff failed to provide an environment that was free from accident hazards and provide adequate supervision to prevent an avoidable accident/elopement for one resident (Resident #113-R113) in a survey sample of 29 residents. R113, while wearing a wander guard device, eloped from the facility, left the premises, fell, and was unable to get up, which resulted in complaints of back pain, requiring treatment and new order for x-rays, constituting harm. During the survey, the survey team identified that the wander guard system was not consistently functioning properly, and immediate jeopardy was identified.

Inspectors wroteBased on resident interviews, staff interviews, observations and facility documentation the facility staff failed to allow the residents to exercise their rights as a citizen of the United States for multiple residents residing on 2 of 2 units and failed to treat residents with and provide an environment that promoted respect and dignity for residents on 1 of 2 nursing units.

Inspectors wroteBased on resident interviews, staff interviews, observations, and facility documentation, the facility staff failed to ensure multiple residents on 2 of 2 units had the opportunity to exercise autonomy regarding voting interests and preferences.

Inspectors wroteBased on resident interviews, staff interviews, observations and facility documentation the facility staff failed to allow the residents to exercise their rights as a citizen of the United States for multiple residents residing on 2 of 2 units and failed to treat residents with and provide an environment that promoted respect and dignity for residents on 1 of 2 nursing units.

Inspectors wroteBased on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to administer the facility in a manner to effectively maintain the highest practicable well-being of each resident, having the potential to affect many residents on 2 of 2 nursing units.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents were clinically appropriate to self-administer medications, before being permitted to do so for three residents (Resident #111- R111, Resident #114- R114, and Resident #121-R121) in a survey sample of 29 residents.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility failed to implement abuse policies for two of seven residents, Resident #'s 203 and 207. The Findings Include: 1. The facility did not implement facility abuse policy in regards to reporting suspicion of physical abuse/mistreatment for Resident #203 (R203). According to the clinical record, diagnoses for R203 included, Multiple sclerosis, quadriplegia, pulmonary embolism, and depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/6/24, which assessed R203 with a cognitive score of 15 out of 15, indicating cognitively intact. [...]

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility failed to report suspicion of physical abuse/mistreatment for one of 7 residents (Resident #203) and failed to report suspicion of physical abuse/mistreatment timely for one of 7 residents (Resident #207) to the state agency. The Findings Include: 1. The facility did not report suspicion of physical abuse/mistreatment for resident #203 (R203). According to the clinical record, diagnoses for R203 included Multiple sclerosis, quadriplegia, pulmonary embolism, and depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/6/24. R203 was assessed with a cognitive score of 15 out of 15, indicating cognitively intact. [...]

Inspectors wroteBased on observations, resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to complete a thorough and accurate investigation of a serious elopement incident involving one resident (Resident #113-R113), in a survey sample of 29 residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement the comprehensive care plan interventions for one resident (resident #113- R113) in a survey sample of 29 residents.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to review and revise the care plan for one resident (resident #113- R113) in a survey sample of 29 residents.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of care during medication administration for two residents (Resident #111- R111 and resident #121- R121) in a survey sample of 29 residents.

Inspectors wroteBased on observation, resident and staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure medications were stored in a secure manner for two residents (Resident #114-R114 and Resident #126-R126) in a survey sample of 29 residents.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for two residents (resident #121- R121 and resident #113-R113) in a survey sample of 29 residents.

Inspectors wrote6. The facility staff neglected to provide incontinence care for Resident #20 (R20), which resulted in the resident lying in feces and urine for an extended period of time. On 8/2/24 at approximately 1:30 p.m., an observation was made of facility staff providing incontinence care to R20. CNA#4 (CNA4), CNA#13 (CNA13), and CNA#14 (CNA14) were in R20's room to provide afternoon incontinence care to the resident. This surveyor observed feces and urine on the bed sheets and incontinent pad under the resident from R21's shoulders to her knees. There was a strong smell of ammonia and odor from the bowel movement. The brief was full, and it had leaked out onto the incontinent pad and sheets. The CNA's had to change the linen on the entire bed. When questioned about the last time incontinence care had been provided to R21, the CNAs did not answer the question. [...]

Inspectors wroteBased on resident interviews, facility staff interviews, clinical record review and facility documentation review, the facility staff failed to report allegations of abuse and sexual harassment by resident #10 (R10), affecting five residents and resulted in psychosocial harm for all five (resident #9, Resident #7, Resident #8, Resident #12 and Resident #13). This failure resulted in immediate jeopardy being identified.

Inspectors wroteBased on resident interviews, facility staff interviews, clinical record review and facility documentation review, the facility staff failed to investigate allegations of abuse and sexual harassment by Resident #10 (R10) who was targeting female residents, and to take measures to protect residents and prevent further potential abuse, which had the potential to affect 59 residents that were female out of 98 residents residing in the facility. This failure resulted in immediate jeopardy being identified and resulted in psychosocial harm for six residents.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide care and services to ensure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being, which resulted in psychosocial harm for five residents (Resident #7- R7, Resident #8- R8, Resident #12- R12, Resident #13- R13, and Resident #15- R15). The resident who was the known aggressor, was targeting female residents. Therefore 59 of the 98 residents residing in the facility who were female, had the potential to be affected. This deficient practice resulted in immediate jeopardy.

Inspectors wroteBased on observations, staff interviews, resident interviews, clinical record review, and facility documentation review, the facility staff failed to provide an environment that was free from accident hazards and provide adequate supervision to prevent an avoidable accident/elopement for one resident (Resident #113-R113) in a survey sample of 29 residents. R113, while wearing a wander guard device, eloped from the facility, left the premises, fell, and was unable to get up, which resulted in complaints of back pain, requiring treatment, and new order for x-rays, constituting harm. During the survey, the survey team identified that the wander guard system was not consistently functioning properly, and immediate jeopardy was identified.

Inspectors wroteBased on resident interviews, staff interviews, and facility documentation review, the facility staff failed to administer the facility in a manner that enables residents to attain or maintain their highest practicable psychosocial well-being and be free from sexual harassment and abuse by a male resident who was targeting female residents, which had the potential to affect the 59 female residents residing on 2 of 2 nursing units, and caused psychosocial harm to residents.

Inspectors wroteBased on resident interviews, staff interviews, observations and facility documentation the facility staff failed to allow the residents to exercise their rights as a citizen of the United States for multiple residents residing on 2 of 2 units and failed to treat residents with and provide an environment that promoted respect and dignity for residents on 1 of 2 nursing units.

Inspectors wroteBased on observation, resident interview, staff interviews, facility documentation review, and clinical record review, the facility staff failed to assess and determine if four residents were safe to self-administer medications, Resident # 16 (R16), Resident # 17 (R17), Resident # 18 (R18) and Resident # 19 (R19), in a survey sample of 28 residents.

Inspectors wroteBased on resident interviews, staff interviews, observations, and facility documentation, the facility staff failed to ensure multiple residents on 2 of 2 units had the opportunity to exercise autonomy regarding voting interests and preferences.

Inspectors wroteBased on observation, staff interviews and facility documentation review, the facility staff failed to have sufficient nursing staff to provide nursing and related services to multiple residents on 1 of 2 units.

Inspectors wroteBased on observation, resident interview, staff interviews, facility documentation review, and clinical record review, the facility staff failed to assure that medications were secure and inaccessible to unauthorized staff and residents, for four residents (Resident # 16 (R16), Resident # 17 (R17), Resident # 18 (R18), and Resident # 19 (R19)) in a survey sample of 28 residents.

Inspectors wroteBased on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to respond to a grievance for one resident (Resident #7- R7) in a survey sample of 28 residents.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility failed to implement abuse policies for two of seven residents, Resident #'s 203 and 207. The Findings Include: 1. The facility did not implement facility abuse policy in regards to reporting suspicion of physical abuse/mistreatment for Resident #203 (R203). According to the clinical record, diagnoses for R203 included, Multiple sclerosis, quadriplegia, pulmonary embolism, and depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/6/24, which assessed R203 with a cognitive score of 15 out of 15, indicating cognitively intact. [...]

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to develop and implement a comprehensive resident centered care plan for one resident (Resident #10- R10) in a survey sample of 28 residents.

Inspectors wrote2. The facility staff failed to revise the care plan for Resident #1 (R1) following a fall, to indicate interventions that were put in place to prevent recurrence. A review of R1's clinical record was performed on 8/6/24. R1 had an unwitnessed fall on 7/2/24. A review of R1's care plan was conducted. This review revealed that the fall care plan had no interventions added or revised since 9/25/23. No interventions were put in place following R1's fall on 7/2/24, to prevent recurrence. A review of the fall incident report was conducted on 8/6/24. R1 had a fall in his room and the report had poor lighting and gait imbalance was the predisposing factors of the fall. The report had that R1 had on normal socks and not non-skid socks. A change in condition note was reviewed on 8/6/24. On 7/2/24 a change in condition form was completed for R1's unwitnessed fall. [...]

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of care during medication administration for two residents (Resident #111- R111 and resident #121- R121) in a survey sample of 29 residents.

Inspectors wroteBased on staff interviews, clinical record review, and facility documentation review, the facility staff failed to develop and implement an effective discharge plan for one resident (Resident #11-R11), in a survey sample of 28 residents.

Inspectors wroteBased on observation, staff interviews, resident interviews and facility documentation review, the facility staff failed to provide services to residents by answering the call bell(s)/requests for assistance, in a timely manner on one of two nursing units.

Inspectors wroteBased on observation, staff interviews, resident interviews, clinical record reviews and facility documentation the facility staff failed to ensure residents received the appropriate treatment and services for incontinence of bowel and bladder for two residents (resident #20 and resident #21) in a survey sample of 28 residents.

Inspectors wroteBased on staff interviews and facility documentation the facility staff failed to complete a yearly performance review for one staff member (Certified nursing assistant, CNA #15) in a sample of eight staff records reviewed.

Inspectors wroteBased on observation, staff interviews, clinical records and facility documents the facility staff failed to provide therapeutic diets for two residents, Resident # 1 (R1) and Resident #2 (R2) in a survey sample of 28 residents.

Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one resident (Resident #9) in a survey sample of 28 residents.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to provide employee QAPI training for six employees in a survey sample of eight employee records reviewed.

Inspectors wroteBased on staff interviews, facility document review, and closed record review, facility staff failed to follow physician's orders to obtain a physician ordered stat x-ray for one of three residents, Resident #3 (R3).

Inspectors wroteBased on clinical record review and staff interview, the facility staff failed to ensure immediate care orders upon admission for Resident #293 regarding diet.

Inspectors wroteBased on medication pass and pour observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure professional standards of nursing were followed during medication administration on one of three units (Unit 2) and one of 29 residents, Resident #293.

Inspectors wroteBased on medication pass and pour observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than five percent. A total of thirty-three medication opportunities were observed with seven errors. This resulted in a medication error rate of 21.21%.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to properly store liquid narcotics in two of three refrigerators, Unit 2 and Unit 3.

Inspectors wroteBased on a closed clinical record review, staff interview and facility document review, the facility staff failed to ensure one of 29 residents' (Resident #293) dietary preferences were taken into consideration.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide alternate menu options of similar nutritive value for three of twenty-nine residents in the survey sample when they chose not to eat food initially served (Residents #20, #25 and #45). Alternate menu options of similar nutritive value were not routinely provided to residents in the facility and not posted and/or communicated in advance for choices prior to the meal.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to store, prepare and serve food in a sanitary manner in the main kitchen.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure essential equipment was in good working order.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to assess two of twenty-nine residents in the survey sample for self-administration of medications (Residents #20 and #293).

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to notify the responsible party (RP) for one of 29 residents (Resident #289). This was a closed record review.

Inspectors wroteBased on observation, family interview, staff interview, and clinical record review, the facility staff failed to provide a clean, homelike environment for one of twenty-nine residents in the survey sample (Resident #2).

Inspectors wroteBased on medication pass and pour observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure One of 29 residents was free from misappropriation of property, Resident #57. Resident #57's medication was borrowed by a staff member to be administered to another resident.

Inspectors wroteBased on staff interview, and clinical record review, the facility staff failed to ensure a discharge summary was completed for one of 29 residents. This was closed record review.

Inspectors wroteBased on Resident interview, staff interview, and clinical record review, the facility staff failed to provide Activities of Daily Living (ADL's) for two of 29 residents (Residents #40 and Resident #293). The Findings Include: 1. Facility staff failed to provide a scheduled shower for Resident #40. Diagnoses for Resident #40 included; Adult failure to thrive, diabetes, major depression, and stage three pressure ulcer. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 1/12/2023. Resident #40 was assessed with a cognitive score of 13 indicating cognitively intact. During the interview with Resident #40 conducted on 2/26/23 at 4:10 PM, Resident #40 verbalized that the staff had not given her a shower on Friday (2/24/23) as scheduled, and went on to say that one of the nursing staff said there wasn't enough towels or washcloths. [...]

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a complete medical record for one of twenty-nine residents in the survey sample (Resident #2).

Inspectors wroteBased on observation, staff interview and facility document review the facility staff failed to ensure proper hand hygiene for one of 29 residents (Resident #40). The Findings Include: Proper hand hygiene was not performed during a dressing change for Resident #40. Diagnoses for Resident #40 included; Adult failure to thrive, diabetes, major depression, and stage three pressure ulcer. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 1/12/2023. Resident #40 was assessed with a cognitive score of 13 out of 15, indicating cognitively intact. On 2/27/23 at 9:53 AM, registered nurse (RN #6) performed a dressing change on Resident #40. [...]

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to ensure garbage and refuse were disposed of properly.

Inspectors wroteBased on review of employee files, and staff interview, and facility document review, the facility failed to fully implement their policy and procedure for licensure and certification verification of new employees. The facility failed to verify the license and/or conduct a criminal background check for eight of 25 employee files reviewed.

Inspectors wroteBased on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to provide information regarding bed holds at the time of transfer/discharge for four of 24 residents, Resident #70, Resident #320, Resident #67, and Resident #61.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to provide a therapeutic diet and nutritional supplements as ordered/recommended for one of twenty-four residents in the survey sample, Resident #51. Resident #51, with severe protein-calorie malnutrition, significant weight loss and poor intake, did not have fortified foods provided as ordered, and was not provided Pro-Stat, Magic Cup or a liberalized regular diet as recommended by the registered dietitian (RD) and/or physician. Resident #51 was not provided assistance with meals when having trouble with eating and drinking.

Inspectors wroteBased on medication pass and pour observation, staff interview, and clinical record review the facility staff failed to ensure a medication error rate less than 5 percent. There were 5 errors out of 26 opportunities resulting in a medication error rate of 19.23 percent.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to provide dignity/respect for two of 24 residents in the survey sample, Resident #51, and #42. Resident #51 was dressed in a soiled hospital gown and was provided physical therapy services with her back, incontinence brief and legs exposed in the presence of a visitor. Resident #42 was abruptly awakened and positioned for breakfast while stating she did not want to eat.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to meet discharge/transfer documentation requirements for three of 24 residents, Resident #70, Resident #320, and Resident #67.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of practice for one of twenty-four residents in the survey sample, Resident #42. Nursing failed to document an assessment and the circumstances regarding a fall in Resident #42's clinical record and incident reports had conflicting details regarding the fall with injury.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to obtain a physician's order prior to obtaining palliative care services for one of twenty-four residents in the survey sample, Resdient #51. Resident #51 had consultation by a transitional/palliative care provider when there was no physician's order or plan of care for palliative/comfort care.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to ensure a hand splint was applied for one of 24 residents in the survey sample, Resident # 8.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to implement care interventions regarding a urinary catheter for one of twenty-four residents in the survey sample, Resident #50. Resident #50's Foley urinary catheter tubing was not stabilized to prevent tension at the insertion site and the urine collection bag was observed in the floor.

Inspectors wroteBased on staff interview, resident interview, and clinical record review, the facility staff failed to obtain a physician's orders for hemodialysis, along with care and maintenance of a dialysis resident, for one of 24 resident in the survey sample, Resident #69; and failed to assess a new dialysis graft site for one of 24 residents in the survey sample, Resident #21.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure drugs and biologicals were labeled appropriately on one of two nursing unit medication rooms, Unit 2. The facility failed to appropriately label one, multi dose vial of Tuberculin on Unit 2.

Inspectors wroteBased on observation and staff interview, the facility staff failed to follow professional standards for food safety in the main kitcehn. Sheet pans identified as clean, dry, and ready to use were not nested wet in the main kitchen.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to provide scheduled oversight/consultation to the dietary manager regarding the facility's food/meal service to residents by the registered dietitian.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to store and serve food in a sanitary manner. An opened package of refrigerated sandwich meat was stored and available for use beyond the discard date. Ten thawed packages sandwich meat, without designated expiration and/or discard dates, were stored in the refrigerator. Three packages of the turkey, identified during the survey with an undetermined storage status, were served during the lunch meal.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure medications were locked in the medication cart during a medication pass and pour observation; failed to properly store insulin in one of three medication carts inspected, and also failed to label and date opened tuberculin solution and Lorazepam (an anti-anxiety medication) in one of three medication rooms inspected.

Inspectors wroteBased on staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to notify the physician of a change in condition for one of 23 residents in the survey sample. There was no notification to the physician when Resident #95 was assessed with edema and diminished lung sounds/wheezing.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to apply physician ordered Ace wraps for one of 23 residents in the survey sample (Resident #151).

Inspectors wroteBased on observation, staff interview, and clinical record review the facility staff failed to properly assess one of 23 residents in the survey sample for the use of bed rails: Resident # 41.

Inspectors wroteBased on observation, staff interview, resident review and clinical record review, the facility staff failed to honor the food preferences for two of 23 residents, Resident #37 and Resident #152.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control practices during a dressing change for one of 23 residents in the survey sample (Resident #151).