The most recent inspection on August 5, 2025, found no deficiencies following a complaint investigation. Earlier inspections showed a mixed pattern with some deficiencies related mainly to staff training and certification, resident admission criteria, medication management, and reporting requirements. Notable issues included substantiated abuse involving a resident in 2021, failure to maintain required employee health screenings and certifications, and admission of non-ambulatory residents not meeting facility criteria. Complaint investigations were mostly unsubstantiated except for the 2021 abuse case, and enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record suggests some improvement over time, with no deficiencies found in the most recent inspections after prior citations.
Deficiencies (last 7 years)
Deficiencies (over 7 years)4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The purpose of this visit was to investigate intake #GA00228376 with an on-site visit made on 11/22/22. The investigation started on 10/31/22 and was completed on 12/6/22.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00228376 was completed with no rule violations cited.
The purpose of this visit was to investigate intake #GA00218420, with an on-site visit made on 2021-11-01 and the investigation completed on 2021-12-09.
Findings
The facility failed to ensure a resident's right to be free from mental, verbal, sexual and physical abuse, neglect, and exploitation. Specifically, Resident #1 was pushed by Staff C, causing the resident to fall and sustain a reddish bruise. Staff C lacked training in dementia behaviors, de-escalation, or crisis intervention.
Complaint Details
The investigation was initiated due to intake #GA00218420 regarding alleged elder abuse involving Resident #1. The complaint was substantiated based on record review, staff interviews, police report, and security footage.
Severity Breakdown
G: 1
Deficiencies (1)
Description
Severity
Facility failed to ensure each resident had the right to be free from mental, verbal, sexual and physical abuse, neglect and exploitation for Resident #1.
G
Report Facts
Date of incident: Oct 14, 2021Staff employment duration: 5Resident admission date: Mar 31, 2020
Employees Mentioned
Name
Title
Context
Staff C
Named in abuse incident involving Resident #1; admitted to pushing resident and lacking dementia and crisis training.
Staff A
Reported Staff C's account to police officer during elder abuse investigation.
The purpose of this visit was to conduct the compliance inspection and investigate intake #GA00215798.
Findings
The facility failed to ensure that the hot water system supplied heated water at a temperature comfortable to the touch but not exceeding 120 degrees Fahrenheit. Observations showed water temperatures of 125.0 and 122.0 degrees Fahrenheit in resident bathroom sinks.
Complaint Details
Visit was complaint-related, investigating intake #GA00215798.
Severity Breakdown
D: 1
Deficiencies (1)
Description
Severity
Facility failed to ensure hot water temperature did not exceed 120 degrees Fahrenheit, with observed temperatures at 125.0 and 122.0 degrees.
D
Report Facts
Water temperature: 125Water temperature: 122Water temperature: 32
Employees Mentioned
Name
Title
Context
Staff A acknowledged the hot water temperatures and stated they would have them adjusted.
The purpose of this visit was to conduct a compliance inspection of Augusta Gardens Retirement Residence.
Findings
The inspection identified deficiencies including failure to ensure all employees had required physical examinations and tuberculosis screenings within 12 months prior to employment, failure to make facility records available for review, and failure to report serious injuries to the Department for two residents who sustained hip fractures.
Severity Breakdown
E: 1D: 2
Deficiencies (3)
Description
Severity
Failure to ensure each employee received a physical examination and TB screening within 12 months prior to employment for 2 of 3 staff (Staff D and Staff E).
E
Failure to make facility records available for review and examination by a properly identified representative of the Department.
D
Failure to report to the Department a serious injury to a resident that required medical treatment for 2 of 6 residents (Resident #5 and Resident #6).
D
Report Facts
Staff without required physical examination and TB screening: 2Residents with unreported serious injuries: 2Residents reviewed for serious injury reporting: 6
Employees Mentioned
Name
Title
Context
Staff D
Failed to have physical examination and TB screening within 12 months prior to employment.
Staff E
Failed to have physical examination and TB screening within 12 months prior to employment.
Staff A
Interviewed and stated Staff D and Staff E did not have required physical examination and TB screening; also stated failure to submit injury report for Resident #6 and inability to locate the report.
Staff B
Interviewed regarding Resident #5 and Resident #6 injuries and rehabilitation.
Staff G
Interviewed and stated no access to facility files during inspection.
The purpose of this visit was to investigate intake # GA00200105.
Findings
The facility failed to ensure that 1 of 2 staff (Staff C) had current certification in emergency first aid, cardiopulmonary resuscitation (CPR) with competency demonstration, and at least sixteen hours of training per year as required.
Complaint Details
Visit was complaint-related to intake # GA00200105. Substantiation status is not stated.
Severity Breakdown
SS= D: 3
Deficiencies (3)
Description
Severity
Facility failed to ensure Staff C had current certification in emergency first aid within the first sixty days of employment.
SS= D
Facility failed to ensure Staff C had current certification in cardiopulmonary resuscitation (CPR) with required return demonstration of competency.
SS= D
Facility failed to ensure Staff C received at least sixteen hours of training per year for 2018.
The purpose of this visit was to investigate intake # GA00195785.
Findings
The facility failed to ensure that only ambulatory residents capable of self-preservation with minimal assistance were admitted and retained, as evidenced by Resident #1 who was non-verbal, bed bound, and unable to assist with daily care or transfers.
Complaint Details
Visit was complaint-related to intake # GA00195785. Resident #1 was found to be non-ambulatory and bed bound, contrary to facility admission requirements.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
The home admitted and retained a non-ambulatory resident who was not capable of self-preservation with minimal assistance.
SS= D
Employees Mentioned
Name
Title
Context
Staff A interviewed regarding Resident #1's condition and communication with POA.
The purpose of this visit was to investigate complaint #GA00194151.
Findings
The facility failed to ensure that one staff member (Staff E) had a physical examination and tuberculosis screening within 12 months prior to employment, maintain evidence of required trainings and certifications for Staff E, and timely obtain medication refills for one resident (Resident #2) to prevent interruption in routine dosing.
Complaint Details
The visit was conducted to investigate complaint #GA00194151. The complaint involved failure to maintain required employee health screenings and certifications, and failure to timely obtain medication refills for residents.
Severity Breakdown
SS= D: 4
Deficiencies (4)
Description
Severity
Facility failed to ensure each employee received a physical examination and TB screening within 12 months prior to employment for 1 of 5 sampled staff (Staff E).
SS= D
Facility failed to maintain a record of a physical examination completed by a licensed provider for 1 of 5 sampled staff (Staff E).
SS= D
Facility failed to maintain evidence of trainings, skills competency determinations and recertifications for 1 of 2 sampled staff (Staff E), including expired CPR and first aid card.
SS= D
Facility failed to ensure timely medication refills to prevent interruption in routine dosing for 1 of 3 sampled residents (Resident #2).
SS= D
Report Facts
Sampled staff: 5Sampled staff: 2Sampled residents: 3Medication administration record date range: 31Medication missing days: 2
The purpose of this visit was to conduct a compliance inspection and investigate complaint #GA00191726.
Findings
The facility failed to meet multiple workforce qualification and training requirements, including lack of current certification in emergency first aid and CPR for some staff, missing physical examinations and tuberculosis screenings, failure to obtain satisfactory criminal records checks prior to employment, admission of non-ambulatory residents not capable of self-preservation, and failure to develop written care plans and provide adequate proxy caregiver training for medication administration.
Complaint Details
The inspection was conducted to investigate complaint #GA00191726.
Severity Breakdown
E: 2D: 5
Deficiencies (7)
Description
Severity
Failed to ensure staff obtained current certification in emergency first aid within the first sixty days of employment for 2 of 4 staff (Staff A and Staff G).
E
Failed to ensure staff received current certification in cardiopulmonary resuscitation (CPR) with competency demonstration for 1 of 4 staff (Staff A).
E
Failed to ensure each employee received a physical examination and tuberculosis screening within 12 months prior to employment for 2 of 4 staff (Staff A and Staff F).
D
Failed to obtain a satisfactory criminal records check prior to employment for 1 of 4 sampled staff (Staff G).
D
Failed to admit and retain only ambulatory residents capable of self-preservation with minimal assistance for 2 of 5 sampled residents (Resident #1 and Resident #2).
D
Failed to ensure a written plan of care was developed by a licensed healthcare professional for proxy caregivers delivering health maintenance activities for 3 of 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #6).
D
Failed to ensure proxy caregivers' training included satisfactory and independent completion of required skills competency checklists for 2 of 4 staff (Staff B and Staff G).
D
Report Facts
Staff sample size: 4Resident sample size: 5Residents not ambulatory: 2Residents without written care plans: 3Staff without first aid certification: 2Staff without CPR certification: 1Staff without physical exam and TB screening: 2Staff without criminal records check: 1Staff without proxy caregiver training: 2
Employees Mentioned
Name
Title
Context
Staff A
Named in findings for lack of first aid and CPR certification, missing physical exam and TB screening.
Staff G
Named in findings for lack of first aid certification, missing criminal records check, and lack of proxy caregiver training.
Staff F
Named in findings for missing physical exam and TB screening.
Staff B
Named in findings for lack of proxy caregiver training.
The purpose of this visit was to investigate multiple complaint intakes related to resident supervision and abuse allegations.
Findings
The facility failed to ensure adequate supervision of residents consistent with their needs, resulting in inappropriate contact between two residents. Additionally, the facility failed to report the incidents of alleged sexual assault and abuse to the Department and local police within 24 hours as required.
Complaint Details
The investigation was triggered by multiple complaint intakes (#GA00190321, #GA00190311, #GA00190242, #GA00190219, #GA00190145, #GA00190172, #GA00190166, #GA00190149, and #GA00190144). The allegations involved inappropriate sexual contact between Resident #1 and Resident #2 and failure to report the incidents timely. The facility did not consider the incidents reportable, despite evidence and police involvement.
Severity Breakdown
SS= D: 2
Deficiencies (2)
Description
Severity
Failure to ensure residents were supervised consistent with their needs, evidenced by inappropriate contact between two residents.
SS= D
Failure to report sexual assault, battery, abuse, neglect, or exploitation of a resident within 24 hours to the Department and local police.
SS= D
Report Facts
Residents in memory care area: 12Direct care staff present: 3Incident report dates: 2
Employees Mentioned
Name
Title
Context
Staff A
Interviewed staff who witnessed incidents and commented on reportability
The purpose of this visit was to conduct a follow-up to the 8/14/17 annual inspection and complaint investigation.
Findings
The facility failed to have work performance reviews, including skills competency checklists, for unlicensed staff performing specialized tasks such as medication administration. Additionally, the facility failed to provide evidence of routine evaluations of continued skills competencies by an appropriately licensed healthcare professional for one staff member.
Complaint Details
The visit was a follow-up to a complaint investigation conducted on 8/14/17.
Severity Breakdown
E: 2
Deficiencies (2)
Description
Severity
Failed to have work performance reviews, including skills competency checklists, for 1 of 2 unlicensed staff (Staff C) who performed medication administration for 3 residents.
E
Failed to provide evidence of routine evaluations of continued skills competencies by an appropriately licensed healthcare professional for 1 of 2 staff (Staff E).
E
Employees Mentioned
Name
Title
Context
Staff C
Unlicensed staff who performed medication administration without completed skills competency checklists or proxy caregiver training.
Staff E
Staff member who had not completed updated proxy caregiver training and lacked evidence of routine evaluations of continued skills competencies.
Staff A
Interviewed staff who provided information about Staff C and Staff E training status.
The purpose of this visit was to conduct an annual inspection and to investigate facility self-reported complaint #GA00178119.
Findings
The facility failed to ensure that staff received required current certifications in First Aid and CPR, failed to maintain evidence of recertifications, lacked initial and annual work performance reviews for unlicensed staff performing specialized tasks including medication administration, failed to document medication skills competency for unlicensed staff, and failed to maintain a complete Medication Assistance Record (MAR) for one resident.
Complaint Details
The visit included investigation of facility self-reported complaint #GA00178119.
Severity Breakdown
SS= D: 6
Deficiencies (6)
Description
Severity
Failed to ensure that each staff received current certification in First Aid for 1 of 9 sampled staff (Staff I).
SS= D
Failed to ensure that each staff received current certification in cardiopulmonary resuscitation (CPR) for 1 of 9 sampled staff (Staff I).
SS= D
Failed to ensure staff files included evidence of recertifications as required for 1 of 9 staff (Staff A) whose CPR and First Aid had expired.
SS= D
Failed to have initial and/or annual work performance reviews including skills competency checklists for 1 of 2 sampled unlicensed staff (Staff C) performing specialized tasks for medication administration to 3 residents.
SS= D
Failed to have documentation of medication skill competency when hired and annually thereafter for 1 of 9 staff (Staff D) providing assistance with or supervision of self-administered medications.
SS= D
Failed to have a Medication Assistance Record (MAR) which included the name, strength and specific directions for use of each medication for 1 of 9 residents (Resident #6).