Resorts of Augsburg

Inspectors wroteBased on record review and interviews, the facility failed to timely implement treatment recommendations for wound management and apply pressure-relieving devices as ordered. This was evident for 3 (Resident #11, #18, and #7) of 3 residents reviewed for wounds during the complaint survey.

Inspectors wroteBased on record reviews and interviews, the facility failed to accommodate resident's preference. This was evident for 2 (Resident #21 and #16) of 3 residents reviewed for preferences during the complaint survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to accurately reflect Resident #8's preferred language. This was evident for one resident (Resident #8) out of three residents reviewed for discharge.

Inspectors wroteBased on facility document review, record review, and interview, it was determined the facility failed to develop a comprehensive plan of care for a resident with known contractures. This was evident for 1 (Resident #9) of 3 residents reviewed for care plans during the complaint survey.

Inspectors wroteBased on record review and interviews, it was determined the facility failed to provide ADL care related to urine incontinence timely to a dependent resident. This was evident for 1 (Resident #16) of 3 residents reviewed for Activities of Daily Living during the complaint survey.

Inspectors wroteBased on record review and interview, it was determined the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not documenting the continued monitoring of a resident with chest pain. This was evident for 1 (Resident #10) of 3 residents reviewed for change in condition during the complaint survey. On 07/21/2026 at approximately 8:00 AM, in review of Intake #3036883, there was a noted concern related to pain management and care services. On 07/23/2026 at 8:33 AM, a review of Resident #10's progress notes from 04/27/2026 at 12:30 PM revealed a physician note: Resident #10 was seen for a post-urology follow-up and left-sided rib cage pain, with new complaints of left-sided pleuritic chest pain (a sharp, stabbing discomfort that worsens when you breathe in, cough, or sneeze) under the left breast. [...]

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to provide appropriate pain management that included documentation of non-pharmacological interventions. This was evident for 3 (Resident #7, #9, and #10) out of 3 residents reviewed for pain during the complaint survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility failed to administer medications to treat urinary tract infections as ordered by a physician. This was evident for 2 (Resident #17 and #7) of 4 residents reviewed for infections during the complaint survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure a functioning call light system for all residents. This was evident for 1 (Resident #6) out of 21 resident call lights observed during initial observations.

Inspectors wroteBased on interviews and clinical record review, the facility failed to ensure one (1) of 14 sampled residents was free from a significant medication error when Resident (R) #7 was prescribed and administered a medication that the resident was documented as being allergic to (acetaminophen).

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to maintain an effective infection control program. Specifically, the facility failed to: 1) follow infection control practices consistent with accepted standards of practice, 2) prevent oxygen tubing from resting on the floor, 3) review and revise infection control policies and procedures annually, and 4) provide required follow-up care for a resident with a major infection. This was evident for 1 out of 4 nursing units reviewed, one of three residents reviewed for oxygen therapy (Resident #6), five of five facility policies reviewed, and one of one resident (Resident #89) reviewed for Transmission-Based Precautions during the facility's recertification survey.

Inspectors wroteBased on review of employee files and interviews with facility staff, it was determined that the facility staff failed to conduct required performance reviews of Geriatric Nursing Assistants (GNAs) at least once every 12 months. This was found to be evident for 8 (GNA #36, GNA #40, GNA #41, GNA #33, GNA #42, GNA #34, GNA #37, GNA #38) out of 10 GNA employee files reviewed during the Sufficient and Competent Nurse Staffing facility task for the facility's recertification survey.

Inspectors wroteBased on review of medical records and interview with facility staff, it was determined that the facility failed to 1) develop policies and procedures that address the time frames for the steps in the MRR process and the steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident 2) ensure a pharmacist conducted a complete MRR, at least monthly 3) ensure monthly Medication Regimen Reviews were completed by the facility's providers, 4) respond to recommendations made by consulting pharmacists in a timely manner, and 5) identify instances where the medication indication was inaccurately documented. This was evident for 2 (Resident #7and #8) out of 5 residents reviewed for unnecessary medications during the facility's recertification survey.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to 1) ensure medications were secured as evidenced by observations of medications left at the bedside and on the floor, and 2) store and label medication in accordance with currently accepted professional principles. This was evident for 2 (Resident #35 and #9) out of 36 residents reviewed, 2 of 3 medication cart observed, and 2 of 2 nursing supply rooms observed during the recertification/complaint survey.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to ensure the labeling, dating, and expiration of nourishment items and that expired food items were discarded. This was observed in the facility's kitchen during the recertification/complaint survey.

Inspectors wroteBased on medical record reviews and staff interviews, it was determined that the facility failed to ensure key essential personnel were present during monthly Quality Assurance (QA) meetings. This was evident in 6 out of 11 monthly QA meeting attendance sheets reviewed during this recertification/complaint survey.

Inspectors wroteBased on interviews with residents and outside agency staff, surveyor observation, review of pertinent documentation, and interview with facility staff, it was determined that the facility failed to maintain an effective pest control program. This was found to be evident during the facility's recertification survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to ensure that advance directives were discussed with residents and/or responsible representatives and failed to ensure that residents were evaluated by two physicians for a decision-making capacity. This was found to be evident for 1 (Resident #6) out of 5 residents reviewed for advance directives during this recertification/complaint survey.

Inspectors wroteBased on review of pertinent documentation and interview with facility staff, it was determined that the facility failed to follow the grievance process and communicate the resolution to the resident. This was evident for 1 (Resident #9) out of 2 residents reviewed for grievances during the recertification/complaint survey.

Inspectors wroteBased on record review and interview with facility staff, it was determined the facility failed to 1) ensure the monitoring of a psychotropic medication for a resident and 2) ensure a resident's medication regimen was free from unnecessary medications. Specifically, the facility prescribed as needed (PRN) psychotropic medication without documentation of a supporting evaluation This was evident for 2 (Resident #7 and #13) out of 5 residents reviewed for unnecessary medications during the facility's recertification/complaint survey.

Inspectors wroteBased on a facility reported incident #2623258, record review and interviews, it was determined that the facility failed to report the investigative results of an alleged resident-to resident interaction which resulted in serious bodily injury, to the Office of Health Care Quality (OHCQ) within 5 working days as required. This was true for 1 of 10 (#2623258) facility reported incident reviewed during the survey process. Findings Included:On 12/3/25 at 11:15 AM, a review of Intake #: 2623258 revealed that Resident #128 reported that Resident #136 punched him/her in the face and turned over his/her wheelchair. On 12/3/25 at 12:48 PM, a review of the facility's documentation related to the above-mentioned incident report revealed that approximately 11:45 PM on 9/19/2025 Resident #128 alleged that he/she was punched in the face by Resident #136. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility staff failed to 1) ensure that a written notice which specifies the duration of the bed-hold policy and return to the facility was provided to the resident and/or to resident representative(s) at the time when the resident was transferred to the hospital, and 2) ensure written notice of a hospitalization and the reason for the hospitalization were provided to the resident and to family. This was evident for 2 (Resident #89 and #128) out of 2 residents sent to the hospital that were reviewed during the recertification/complaint survey. Findings Included:Situation, Background, Assessment, and Recommendation (SBAR) is a communication tool that aides healthcare professionals to share information about a patient's condition in a concise manner. [...]

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to accurately code Minimum Data Set (MDS) assessments. This was evident for two (Resident #4 and #8) of five residents reviewed during this recertification/complaint survey.

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to incorporate the recommendations from the Pre-admission Screening and Resident Review Level II determination and evaluation report into the resident's care and refer residents to the appropriate state-designated authority for review when a resident was identified with newly evident or possible serious mental disorders, intellectual disabilities, or a related condition. This was evident for 1 resident (Resident #83) of 4 residents reviewed for PASARR during the recertification survey.

Inspectors wroteBased on a medical record review and an interview with facility staff, it was determined that the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) form was completed prior to or upon admission to the facility. This was evident during the review of two residents (Resident #5 and #13) of the 3 residents reviewed for PASARR screening during this recertification/complaint survey.

Inspectors wroteBased on review of medical records and interviews with facility staff, it was determined that the facility failed to ensure a written summary of the baseline care plan, including a current list of medications, was provided to the resident and/or resident representative (RP) and evidence in the resident's medical record that it was provided. This was evident for 1 (Resident #98) out of 36 residents reviewed during the investigation phase of the facility's recertification survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to 1)develop and implement person-centered comprehensive care plans as required and 2) to ensure interventions agreed to as part of a resident's care plan are initiated. This was evident for three (Resident #5, # 9 and #29) of 76 residents care plans reviewed during the survey process. Findings Included:The Minimum Data Set (MDS) is a standardized comprehensive assessment tool that measures health status in nursing home residents. 1) On 12/01/2025 at 11:09 AM, in an interview with Resident #9, the resident reported that he/she had multiple urinary tract infections since admission. On 12/08/2025 9:44 AM, a review of Resident #9 medical records revealed that the resident had a positive urine culture for urinary tract infection (UTI) on 6/22/2025 at 09:00 AM. [...]

Inspectors wroteBased on resident and staff interviews and review of the medical record, it was determined the facility failed to ensure that dependent resident's personal hygiene needs were adequately met by providing incontinence care in a timely manner. This was evident for 1 (Resident #9) out of 2 residents reviewed for Activities of Daily Living (ADL's) during the facility's recertification survey.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to: 1) ensure that the resident received treatment and care by assisting a resident with transportation to medical appointments and 2) meet the professional standards of practice during medication administration task. This was evident for 1 (Resident #9) of 2 Resident reviewed for missed medical appointments. This was evident for 1 of 29 opportunities for medication error observed during the medication administration task reviewed during the recertification/complaint survey. Findings Included1) On 12/01/2025 10:45 AM, in an interview with Resident #9, the resident alleged they stopped me from getting mobility. I got the form to renew it, and all the facility had to do was give them the size of my wheelchair and have the doctor sign it and they wouldn't. [...]

Inspectors wroteBased on observation, record review and interviews, it was determined that the facility failed to ensure that the resident received assistive devices to maintain vision abilities. This was true for 1 (Resident #9) of 2 Residents reviewed for vision impairment during the recertification/complaint survey. Finding Included:On 12/01/2025 at 10:57 AM, in an interview with Resident #9, the resident explained that he/she got fitted for glasses, but he/she never received the glasses, and it has been a few months. During the interview, the surveyor did not observe the resident in possession of any glasses at bedside. On 12/08/2025 at 2:36 PM, a review of a progress note written on 7/29/2025 at 1:27 PM revealed that Resident #9 went to eye appointment in-house this morning. [...]

Inspectors wroteBased on resident interview and staff interview it was determined that the facility staff failed to ensure a resident's colostomy bag was monitored and changed as needed by staff. This was evident for 1 (Resident #2) out of 1 resident reviewed for colostomy care during the recertification/complaint survey.

Inspectors wroteBased on a review of resident medical records and an interview with facility staff, it was determined that the facility failed to timely address significant weight loss for a resident. This was evident for two (Residents #6 and #13) of the four residents reviewed for nutrition during this recertification/complaint survey.

Inspectors wroteBased on surveyor observation, review of the medical record, and interview with facility staff, it was determined that the facility staff failed to provide necessary respiratory care services by failing to document the indication for oxygen therapy, failing to properly label the oxygen tubing, and failing to administer oxygen at the prescribed flow rate. This was evident for 1 (Resident #6) of 3 residents reviewed for Respiratory Care during this recertification/complaint survey.

Inspectors wroteBased on resident interview and observation of a test tray, it was determined that the facility staff failed to ensure residents are served hot and palatable meals. This was evident for 5 (Residents #2, 9, 50, 98, 110) out of 47 residents in the survey sample.

Inspectors wroteBased on review of medical records and interviews with facility staff, it was determined that the facility failed to 1) maintain a medical record in the most accurate form for residents and 2) ensure that residents' indication of medication was documented. This was evident for 3 (Resident #7, #8, and #11) out of 27 residents reviewed during the facility's recertification/complaint survey.

Inspectors wroteBased on interviews and a review of medical records and facility documentation, it was determined that the facility failed to properly monitor and track antibiotic usage and resistance data. Specifically: 1) the facility's antibiotic stewardship log failed to include essential elements of antibiotic use, and 2) an antibiotic was initiated for a resident before the infecting organism was identified by the laboratory. This deficiency affected one of five residents (Resident #7) reviewed for antibiotic use and the antibiotic stewardship program during the recertification/complaint survey.

Inspectors wroteBased on medical record reviews and staff interviews, it was determined that the facility failed to document the provision of education regarding the benefits, risks, and potential side effects of the COVID-19 vaccine to residents. Additionally, the facility failed to maintain required documentation related to staff COVID-19 vaccination status.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure residents had access to call bells. This was evident for 1 (Resident #12) resident observed during the surveyor's initial tour of the facility during the recertification survey.

Inspectors wroteBased on surveyor observation and interviews with facility staff, it was determined that the facility failed to include all the required staffing information daily and post the staffing information at the beginning of each shift. This was evident for 5 out of 5 days of staffing information reviewed and 1 out of 1 observations of the posted staffing information during the recertification/complaint survey.

Inspectors wroteBased on reviews of the facility investigation and other pertinent information, reviews of a closed medical record, and staff interview, it was determined that the facility 1) failed to report allegations of possible abuse to the local police within 2 hours when a resident (# 255) was identified with an injury of unknown source (fracture). and 2) failed to notify the state agency within 2 hours of a potential abuse/neglect incident. This was evident for 4 (Resident # 69, # 54 and # 10, #255) of 9 residents reviewed for abuse during the recertification survey.

Inspectors wroteBased on observations and interviews with facility staff, it was determined that the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors. This was evident for 2 (Watersedge and Sudbrook) of 4 units in the facility reviewed for staffing information.

Inspectors wroteBased on observations and staff interviews it was determined the facility failed to: 1) store food in accordance with professional standards for food safety; 2) ensure that staff are preparing food under sanitary conditions; and 3) ensure that appropriate testing supplies were not outdated to evaluate the safe operation of the facility kitchen dishwasher. This was evident during the kitchen observation of the recertification survey.

Inspectors wroteBased on administrative and medical record reviews and staff interview, it was determined that the facility failed to: 1) accurately maintain medical records for a resident (# 19); and 2) maintain a completed copy of an investigation into an allegation of staff to resident abuse; 3) provide complete access to closed resident electronic medical records; and 4) identify and maintain accurate electronic medical records by having nursing staff members signing off resident care that was performed by the assigned staff member. This was evident for 8 of 8 records reviewed for accuracy of medical records during an recertification survey.

Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program in place to address identified quality deficiencies. This was found to be evident during the facility's survey. The findings Include: During the facility's current survey conducted on April 4, 2024, thru April 18, 2024, deficient practice was identified in the following areas: Quality of Care with one example of a resident (# 17) who did not receive pain medication with a suspected fracture, Supervision of residents with a history of wandering, Functioning call bell system and Neglect and Abuse allegations. An employee (# 85) was terminated in December 2023 for not following protocols for providing Activities of Daily Living (ADL's) assistance to a resident (#1). [...]

Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least on a quarterly basis to address identified concerns and evaluate the effectiveness of their action plan. This was found to be evident during a review of the facility's Quality Assurance Performance and Improvement (QAPI) meeting attendance sheets during the survey.

Inspectors wroteBased on observations and interviews it was determined the facility failed to maintain a working call bell system. This was evident for 1 resident (#5) out of 7 residents and 2 rooms (#113 and #127) out of 6 rooms during the survey.

Inspectors wroteBased on observations, resident and staff interviews , and record reviews, it was determined that the facility failed to treat residents with respect and dignity in an environment that promotes enhancement of quality of life. This was evident for 3 (Resident #55, #81, #84) out of 4 residents reviewed for dignity during the recertification survey.

Inspectors wroteBased on administrative and medical record review, and interviews with facility staff it was determined the facility failed to keep a resident safe from neglect when an employee failed assist a resident with Activities of Daily Living (ADL) as required. This was found to be evident for 1 (Resident #1) of 9 residents reviewed for abuse during the survey.

Inspectors wroteBased on administrative and medical record review and interviews with facility staff, it was determined the facility failed to complete a thorough investigation into abuse allegations for a resident with an injury of unknown origin. This was found to be evident for 1 (Resident # 1) of 9 residents reviewed for abuse during the survey.

Inspectors wroteBased on resident medical record review and interviews it was determined the facility failed to provide a resident and his/her representative a complete summary or complete written summary of the resident's initial baseline care plan. This was evident for 1 resident (#17) out of 53 residents reviewed during the survey.

Inspectors wroteBased on administrative and medical record review, and interviews with facility staff it was determined the facility failed to develop a care plan for a resident at risk for wandering. This was found to be evident for 1 (Resident # 73) of 7 residents reviewed for accidents during the facility's survey.

Inspectors wroteBased on record review and interview with facility staff, it was determined that facility nursing staff failed to follow professional standards of nursing when documenting medications. This was evident for 1 of 9 residents (Resident #260) reviewed for abuse.

Inspectors wroteBased on reviews of a closed medical record and staff interview, it was determined that the facility nursing staff failed to update a resident's physician prescribed wound care treatment orders after the facility wound consultant updated the treatment orders after a weekly assessment. This was evident for 1 (Resident #257) 4 residents reviewed for pressure ulcers during the recertification survey.

Inspectors wroteBased on administrative and record review it was determined the facility failed to provide adequate supervision for residents at risk for wandering. This was found to be evident for 2 (Resident # 73 and # 54) of 10 residents reviewed for wandering during the facility's survey.

Inspectors wroteBased on record review and interview it was determined that facility staff failed to notify the provider when a resident reported that their pain medication was ineffective. This was evident for 1 (#26) of 3 residents reviewed for pain management.

Inspectors wroteBased on medical record reviews and staff interviews, it was determined that the physician or medical director did not address the pharmacist medication regimen recommendation. This was evident for 1(Resident #26) of 5 residents reviewed for medication regimen reviews.

Inspectors wroteBased on interviews and observations it was determined the facility failed to provide resident (#41) with an accurate menu of meals being served and offering resident (#41) food preference choices as well as other alternative food options. This was evident for 1 resident (#41) out of 53 residents reviewed during the survey.

Inspectors wroteBased on interview and observation it was determined the facility failed to provide resident (#41) with drinks that are consistent with resident needs as stated on his/her meal ticket. This was evident for 1 resident (#41) out of 53 residents reviewed during the annual survey.

Inspectors wroteBased on review of employee files and online sources and interviews with facility staff, it was determined that the facility failed to ensure Geriatric Nursing Assistant (GNA) staff had active, current certification. This was evident for 1 of 5 GNAs (GNA #11) reviewed for staff qualifications during the survey.

Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to maintain infection control practices as evidenced by having uncovered linen carts, a pillow and two pads for side rails on the floor in the linen closet, and the soap and hand sanitizer dispensers were empty in the Soiled Utility Room on the unit Sudbrook. This deficient practice was evident for one linen closet and one utility room observed during the survey.

Inspectors wroteBased on observation and interviews it was determined that the facility staff failed to notify maintenance personnel of maintenance problems on the unit Sudbrook. The deficient practice was evident on 1 unit.

Inspectors wroteBased on review of facility policy and employee files and interviews with facility staff, it was determined that the facility failed to ensure staff participation in mandatory abuse training. This was evident for 1 of 5 Geriatric Nursing Assistants (GNA #43) reviewed for abuse training during survey.

Inspectors wroteBased on the review of employee records and staff interview, it was determined that the facility failed to provide documentation that a Geriatric Nursing Assistance's (GNA) was given abuse training at least once every 12 months. This was evident for 1 of 4 GNA employee records (Staff #25) reviewed during the sufficient and competent nursing staffing task during the recertification survey.

Inspectors wroteBased on observation of medication pass and interview, it was determined the facility staff failed to obtain a medication error rate less than 5% (Residents #22, #16 and #20). This includes 3 out of 6 residents observed for medication pass, 21 errors out of 35 opportunities with a medication error rate of 62.86%.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure residents' dignity was maintained. This was evident for 4 out of the 34 residents reviewed as part of the survey:

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to void an older MOLST form located in a resident's active medical record for Resident (#73) and failed to ensure an advance directive which allowed for medical decisions was in place for Resident (#129). This was evident for 2 of 5 residents selected for review of advance directives and 2 of 38 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to provide the resident and their representative with a summary of the baseline care plan within 48 hours of admission to the facility. This was evident for 1 (Resident #97) of 3 residents reviewed during an annual recertification survey.

Inspectors wroteBased on interview, observation and medical record review the facility staff failed to provide all treatments and services as ordered by the physician for Residents (#22 and #76). This is evident for 2 out of 2 residents selected for review during the investigation stage of the survey process. 1. A review of Resident #76's clinical record revealed that the resident's primary physician wrote an order for the resident to receive Boost Breeze (a nutritional supplement) 8 ounces one time a day and document the percentage of the supplement consumed each time. A review of the Medication Administration Record for March, April, May and June of 2019 revealed that nursing staff has not documented the amount consumed as ordered. The Director of Nursing was interviewed on 06/19/19 at 09:47 AM. She confirmed that the nursing staff did not document the amount of Boost Breeze consumed. 2. [...]

Inspectors wroteBased on medical record review and interview, the facility staff failed to perform and/or document weekly skin and wound assessments for a Resident (#43) with a pressure ulcer. This was evident for 1 out of 6 residents selected for review during the investigation stage of the survey process.

Inspectors wroteBased on record review, observation and staff interview, it was determined the facility staff failed to ensure that the resident's environment was free from potential accidents (#77). This was evident for 1 of 38 residents selected for review during the annual survey process.

Inspectors wroteBased on record review, observation and interview, it was determined the facility staff failed to apply 1/4 side rails to a resident's bed (#86) as ordered. This was evident for 1 of 38 residents selected for review during the annual survey process.

Inspectors wroteBased on observation, it was determined the facility staff failed to properly store medications. This was observed once during an annual recertification survey.