Inspection Reports for Harborview Health Center of Augusta
3618 J DEWEY GRAY CIRCLE, AUGUSTA, GA, 30909
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 12, 2025, identified deficiencies related to life safety code compliance, including non-working exit signs, fire alarm trouble codes, leaking sprinkler heads, missing light globes, and absent oxygen storage signage. Earlier inspections showed a mixed pattern, with the June 5, 2025 state licensure survey finding no health deficiencies, but a routine survey on the same dates citing multiple issues such as incomplete care plans, medication management problems, infection control lapses, and food storage concerns. Prior reports also noted deficiencies in resident confidentiality, wound care, grievance procedures, bathing preferences, and medication administration, with some complaint investigations substantiated and others unsubstantiated. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The inspection history reflects ongoing challenges in clinical care and safety practices, with some recent improvement in state licensure compliance but persistent issues in Medicare/Medicaid regulatory areas.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
227% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
112 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Life Safety
Deficiencies: 5
Date: Jun 12, 2025
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and related NFPA standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including non-working exit signs, fire alarm panel trouble codes, leaking sprinkler heads, missing light globes, and missing oxygen storage signage. These deficiencies affected various areas and numbers of people within the facility.
Deficiencies (5)
Exit sign on the 300 Hall was not working when tested.
Fire alarm panel had trouble codes.
Sprinkler head in the kitchen freezer was not installed correctly and was leaking.
Light fixtures were missing globes, including a light in the pantry on 300 Hall.
Oxygen storage rooms on 300 and 500 Hall were missing empty storage signage.
Report Facts
People affected: 20
People affected: 20
People affected: 10
People affected: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews |
Inspection Report
Routine
Deficiencies: 10
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to residents' rights, care planning, pressure ulcer prevention and care, foot care, respiratory care, pain management, pharmaceutical services, medication labeling and storage, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide written information on advance directives, incomplete care planning for pressure ulcer prevention, inadequate pressure ulcer care, failure to arrange podiatry services, improper maintenance of respiratory equipment, inadequate pain management, missing medications, improper labeling and storage of insulin, food safety violations, and lapses in infection prevention and control practices.
Deficiencies (10)
Failed to provide resident and/or representatives with written information of the right to accept or refuse medical or surgical treatment and/or formulate an advance directive.
Failed to update care plan interventions to include measures to prevent pressure ulcers after resident acquired three pressure ulcers post hospital readmission.
Did not ensure preventative measures were in place to avoid development of pressure ulcers; resident acquired three pressure ulcers after readmission.
Failed to arrange podiatry services for two residents at risk for foot complications.
Failed to ensure respiratory equipment was maintained and stored appropriately, including dirty oxygen concentrator and outdated suction tubing.
Failed to ensure pain management for resident by not having fentanyl patches available, inconsistent pain assessment, and failure to notify physician of missed pain medication.
Failed to ensure medications were available for residents, resulting in missed doses of multiple medications including fentanyl patches and others.
Failed to ensure insulin pens or vials were labeled, dated when opened, and discarded after expiration on two medication carts.
Failed to ensure all items in refrigerator and freezer were sealed, labeled, and dated, risking foodborne illness.
Failed to ensure staff wore gowns and performed hand hygiene appropriately during care of residents on Enhanced Barrier Precautions and failed to sanitize blood pressure cuffs between residents.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Medication doses missed: 5
Medication doses missed: 2
Medication doses missed: 3
Medication doses missed: 13
Residents affected: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding advance directives, pain management, medication availability, insulin labeling, infection control |
| Licensed Practical Nurse 1 | LPN | Interviewed regarding pain management and medication availability |
| Licensed Practical Nurse 2 | LPN | Observed and interviewed regarding pain medication administration and medication cart |
| Wound Care/Registered Nurse | WC/RN | Interviewed and observed regarding wound care and pain management |
| Certified Nursing Assistant 1 | CNA | Observed providing care without gown and hand hygiene |
| Certified Nursing Assistant 2 | CNA | Observed providing care without gown and hand hygiene |
| Certified Medication Aide 1 | CMA | Observed failing to sanitize blood pressure cuff |
| Certified Medication Aide 2 | CMA | Observed failing to sanitize blood pressure cuff |
| Regional Nurse Consultant 2 | RNC | Interviewed regarding podiatry services |
| Social Services Director | SSD | Interviewed regarding podiatry services |
| Administrator | Facility Administrator | Interviewed regarding respiratory care, food safety, and infection control |
| Licensed Practical Nurse 3 | LPN | Interviewed regarding insulin labeling and expiration |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 5, 2025
Visit Reason
A State Licensure survey was conducted at Harborview Health Center of Augusta from June 2, 2025 through June 5, 2025 to assess compliance with state health regulations.
Findings
The survey revealed that there were no State Health deficiencies cited during the inspection period.
Inspection Report
Routine
Census: 112
Deficiencies: 11
Date: Jun 5, 2025
Visit Reason
A standard survey was conducted from June 2 through June 5, 2025, including investigation of multiple complaint intake numbers, some substantiated with deficiencies cited.
Complaint Details
Complaint Intake Numbers GA00254503, GA00254478, and GA00254832 were substantiated with deficiencies cited. Multiple other complaint intake numbers were investigated and found unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations with deficiencies including failure to provide written information on advance directives, failure to update care plans for pressure ulcer prevention, failure to arrange podiatry services, improper maintenance of respiratory equipment, inadequate pain management, medication availability issues, improper insulin storage and labeling, food storage and labeling deficiencies, failure to follow infection control practices, and inadequate antibiotic stewardship monitoring.
Deficiencies (11)
Failed to provide resident or representative with written information about the right to accept or refuse medical or surgical treatment and to formulate advance directives.
Failed to update care plan interventions to prevent pressure ulcers for a resident who developed three pressure ulcers after hospital readmission.
Failed to ensure preventative measures to avoid pressure ulcers for a resident at risk who acquired three pressure ulcers after readmission.
Failed to arrange podiatry services for two residents reviewed for activities of daily living.
Failed to maintain and store respiratory equipment appropriately for a resident with a tracheostomy, including dirty oxygen concentrator and outdated suction tubing.
Failed to manage pain adequately for a resident by ensuring availability of fentanyl patches, consistent pain assessment, and physician notification of missed medication.
Failed to ensure medications were available for two residents, resulting in missed doses of multiple medications including pain and cardiac drugs.
Failed to ensure insulin pens and vials had pharmacy labels, were dated when opened, and were discarded after expiration on two medication carts.
Failed to ensure all items in kitchen refrigerator and freezer were sealed, labeled, and dated, risking foodborne illness for residents.
Failed to ensure staff wore gowns and performed hand hygiene before, between, and after glove changes during personal care and wound care, and failed to sanitize blood pressure cuffs between residents.
Failed to monitor and evaluate antibiotic usage for two residents, including lack of documentation supporting prophylactic antibiotic use and lack of awareness by infection preventionist.
Report Facts
Complaint Intake Numbers Investigated: 21
Resident Census: 112
Pressure Ulcers Developed: 3
Fentanyl Patch Doses Missed: 5
Insulin Pens/Vials Expired or Undated: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Stated no record of resident R59 being given information about advance directives; unaware of missing fentanyl patches for R107. |
| Licensed Practical Nurse 1 | LPN | Reported resident R80 refused to get out of bed due to pain and was repositioned with wedges. |
| Wound Care/Registered Nurse | WC/RN | Revealed resident R80 was to have heels elevated; failed to perform hand hygiene during wound care for R97. |
| Certified Nursing Assistant 1 | CNA | Failed to wear gown and perform hand hygiene during personal care for resident R107. |
| Certified Nursing Assistant 2 | CNA | Failed to wear gown and perform hand hygiene during personal care for resident R107; failed to sanitize blood pressure cuff between residents. |
| Regional Nurse Consultant 2 | RNC | Stated podiatry visits occur monthly unless acute concern; could not provide podiatry roster. |
| Social Services Director | SSD | Stated new podiatry provider starting 6/5/2025; admitted no podiatry visits for some time. |
| Administrator | Facility Administrator | Acknowledged infection control importance for resident with tracheostomy; unaware of missing medications; stated staff must be educated on food labeling and dating. |
| Infection Preventionist | IP | Unaware residents R25 and R33 were on prophylactic antibiotics; tracks infections monthly; agreed antibiotic stewardship monitoring needed improvement. |
| Physician | Physician for Resident R25 | Supported prophylactic antibiotic use for R25 despite limited UTI history. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the unavailability of medications for residents R107 and R220, including missing narcotics and other prescribed drugs.
Complaint Details
The investigation was complaint-driven based on reports that medications were not available for residents R107 and R220. The Director of Nursing and staff were unaware of the missing medications until the investigation. Family member of R220 expressed upset over the medication unavailability.
Findings
The facility failed to ensure medications were available for two residents, resulting in missed doses of critical medications including narcotics and other prescribed drugs. Additionally, insulin pens and vials were not properly labeled or discarded after expiration, increasing the risk of ineffective treatment.
Deficiencies (2)
Failure to provide pharmaceutical services to meet the needs of residents, resulting in missing medications for two residents (R107 and R220).
Failure to ensure insulin pens or vials had pharmacy labels, were dated when opened, and were discarded after expiration on two medication carts.
Report Facts
Dates medications not available for R107: 12
Dates medications not available for R220: 5
Medication carts inspected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding unawareness of missing medications and expectations for insulin labeling. |
| Registered Nurse 1 | Registered Nurse (RN)1 | Interviewed with DON about unawareness of missing fentanyl patches and other medications. |
| Licensed Practical Nurse 2 | Licensed Practical Nurse (LPN)2 | Interviewed about missing fentanyl patches on medication cart. |
| Licensed Practical Nurse 3 | Licensed Practical Nurse (LPN)3 | Interviewed about insulin labeling and expiration issues on medication carts. |
Inspection Report
Abbreviated Survey
Census: 104
Deficiencies: 0
Date: Oct 4, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted at Harborview Healthcare Augusta to investigate Complaint Intake Numbers GA00250996 and GA00251078.
Complaint Details
Complaint Intake Number GA00250996 was unsubstantiated. Complaint Intake Number GA00251078 was substantiated. No deficiencies were cited for either complaint.
Findings
Complaint Intake Number GA00250996 was found unsubstantiated with no deficiency cited. Complaint Intake Number GA00251078 was substantiated with no deficiency cited.
Inspection Report
Deficiencies: 0
Date: Jun 17, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Harborview Health Center of Augusta, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 115
Deficiencies: 0
Date: Jun 17, 2024
Visit Reason
A health revisit survey was conducted to verify correction of previously cited deficiencies from a Complaint Investigation survey concluded on April 25, 2024.
Complaint Details
This visit was a follow-up to a Complaint Investigation survey concluded on April 25, 2024, verifying correction of deficiencies.
Findings
All previously cited deficiencies from the prior Complaint Investigation survey were found to be corrected during this revisit survey.
Inspection Report
Renewal
Deficiencies: 4
Date: Apr 25, 2024
Visit Reason
The inspection was a State Licensure survey conducted at Harborview Health Center of Augusta from April 23, 2024 through April 25, 2024 to determine compliance with the State Long Term Care Requirements.
Findings
The facility was found to have deficiencies related to confidentiality of resident information, grievance procedure noncompliance, inadequate wound care for a stage IV sacral ulcer, and incomplete clinical record documentation for multiple residents. No State Health deficiencies were cited.
Deficiencies (4)
The facility failed to ensure personal information was kept confidential for two residents as medication cards containing resident information were left unattended on top of the medication cart.
The facility failed to ensure grievance procedures were followed for one resident; grievance forms lacked follow-up documentation and written responses.
One resident with a stage IV sacral pressure ulcer had no dressing covering the wound, leaving it exposed to urine and feces.
Clinical records for three residents were incomplete and contained inaccurate documentation, including missed medication administration records and missing documentation of personal hygiene and nutrition intake.
Report Facts
Sampled residents: 20
Residents with confidentiality issue: 2
Residents with grievance procedure issue: 1
Residents with wound care deficiency: 1
Residents with incomplete clinical records: 3
BIMS score: 10
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 5 | Licensed Practical Nurse | Confirmed medication cards were left unattended and explained proper disposal procedure |
| Administrator | Stated expectations for medication card disposal and grievance resolution timelines | |
| Social Services Director | SSD | Discussed grievance tracking and resolution process |
| Regional Nurse | Interim Director of Nursing | Involved in grievance process and commented on documentation |
| Wound Care Nurse | WCN | Confirmed wound dressing was missing and explained wound care procedures |
| Assistant Director of Nursing | ADON | Explained staff expectations for wound dressing maintenance |
| Certified Nurse Aide 5 | CNA | Unaware of wound dressing issue but stated she would notify nurse if it occurred |
| Certified Nurse Aide 4 | CNA | Stated she would notify nurse if wound dressing was soiled or dislodged |
| Regional Nurse | Nurse | Stated missing medication documentation should have been recorded as given |
Inspection Report
Abbreviated Survey
Census: 111
Deficiencies: 4
Date: Apr 25, 2024
Visit Reason
An Abbreviated Survey was conducted at Harborview Health Center of Augusta investigating multiple complaint intake numbers, some of which were substantiated with federal deficiencies.
Complaint Details
The survey was initiated to investigate multiple complaint intake numbers. Several complaints were found unsubstantiated, while four complaint intake numbers were substantiated with federal deficiencies.
Findings
The survey found deficiencies related to confidentiality breaches with resident medication cards left unattended, failure to follow grievance procedures for a resident, inadequate treatment of a stage IV sacral pressure ulcer, and incomplete clinical records for three residents.
Deficiencies (4)
Failed to ensure personal information was kept confidential for two residents; medication cards were left unattended on top of the medication cart.
Failed to ensure grievance procedures were followed for one resident; grievance form lacked follow-up and resolution documentation.
Failed to ensure a dressing was maintained for a stage IV sacral pressure ulcer for one resident; wound was exposed to urine and feces.
Failed to ensure clinical records were complete and accurately documented for three residents; missing medication administration documentation and incomplete care documentation.
Report Facts
Residents present: 111
Complaint Intake Numbers Investigated: 14
Complaint Intake Numbers Substantiated: 4
Resident Sample Size: 20
BIMS Score: 10
BIMS Score: 13
Medication doses missed: 10
Missing documentation dates: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 5 | LPN | Confirmed medication cards were left unattended and demonstrated proper disposal procedure |
| Administrator | Provided expectations for medication card disposal and grievance resolution timelines | |
| Social Services Director | SSD | Responsible for logging grievance forms and tracking resolutions |
| Regional Nurse | Interim Director of Nursing | Involved in grievance follow-up and confirmed missing medication documentation |
| Wound Care Nurse | WCN | Confirmed wound dressing was missing and explained wound care procedures |
| Assistant Director of Nursing | ADON | Stated expectations for staff to alert nursing when wound dressing is soiled or dislodged |
| Certified Nurse Aide 5 | CNA | Unaware of missing wound dressing but would notify nurse if observed |
| Certified Nurse Aide 4 | CNA | Would notify nurse if wound dressing was soiled or missing during care |
Inspection Report
Routine
Deficiencies: 4
Date: Apr 25, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, grievance procedures, pressure ulcer care, and clinical record maintenance at Harborview Health Center of Augusta.
Findings
The facility was found deficient in maintaining confidentiality of resident information, following grievance procedures, providing appropriate pressure ulcer care, and ensuring complete and accurate clinical documentation for several residents. Deficiencies were noted in unattended medication cards exposing resident information, incomplete grievance follow-up, exposed pressure ulcer wounds without dressing, and missing documentation in medical records.
Deficiencies (4)
Failed to ensure personal information was kept confidential; medication cards with resident information were left unattended on medication cart.
Failed to ensure grievance procedures were followed; grievance form lacked follow-up documentation and resolution details.
Failed to provide appropriate pressure ulcer care; a stage IV sacral ulcer was left exposed without dressing.
Failed to maintain complete and accurate clinical records; missing medication administration documentation and incomplete care documentation for multiple residents.
Report Facts
Residents sampled: 20
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Missing medication administration dates: 8
Missing intake documentation dates: 5
Missing personal hygiene and bladder elimination documentation dates: 12
Missing amount eaten documentation dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 5 | LPN | Confirmed medication cards were left unattended and explained proper disposal procedure |
| Administrator | Provided expectations for medication card disposal and grievance resolution timelines | |
| Social Services Director | SSD | Discussed grievance tracking and resolution process |
| Regional Nurse | Interim Director of Nursing | Involved in grievance process and commented on documentation |
| Wound Care Nurse | WCN | Confirmed exposed pressure ulcer wound and dressing care expectations |
| Assistant Director of Nursing | ADON | Stated expectations for staff to alert nurse and replace wound dressings |
| Certified Nurse Aide 5 | CNA | Unaware of wound dressing off but would notify nurse if noticed |
| Certified Nurse Aide 4 | CNA | Stated she would notify nurse if dressing came off or was soiled |
| Regional Nurse | Stated missing medication documentation should have been recorded accurately | |
| Administrator | Confirmed missing documentation and expectation for accurate care documentation |
Inspection Report
Deficiencies: 0
Date: Jan 29, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Harborview Health Center of Augusta, indicating a regulatory inspection was conducted.
Findings
The report contains an initial comment section but does not provide specific details or findings within the visible content.
Inspection Report
Follow-Up
Census: 113
Deficiencies: 0
Date: Jan 29, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited during the December 10, 2023 recertification survey and complaint investigation.
Findings
All deficiencies cited as a result of the December 10, 2023 recertification survey in conjunction with a complaint investigation were found to be corrected.
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 10, 2023
Visit Reason
The inspection was conducted as a State Licensure survey at Harborview Health Center of Augusta from December 8 through December 10, 2023, to determine compliance with State Long Term Care Requirements.
Findings
The facility was found deficient in assessing a resident's ability to self-administer topical medications, honoring bathing preferences for a resident, and ensuring proper verification and use of a PEG tube for medication administration. Deficiencies included failure to assess self-administration ability for one resident, failure to provide scheduled showers and follow care plans for two residents, and failure to verify PEG tube placement before medication administration.
Deficiencies (3)
Failure to assess one resident (R11) receiving topical medications for ability to self-administer, risking medication error and effectiveness.
Failure to honor bathing preferences and provide scheduled showers for one resident (R64), resulting in inadequate bathing care.
Failure to verify PEG tube placement before medication administration and improper medication administration technique for one resident (R86).
Report Facts
Residents assessed for self-administration: 20
Residents reviewed for care plans: 36
Residents receiving medications via PEG tube: 7
BIMS score for R11: 11
BIMS score for R64: 13
Scheduled showers per week for R64: 3
Documented showers for R64 in December 2023: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) AA | Mentioned in relation to failure to assess self-administration and improper PEG tube medication administration | |
| Licensed Practical Nurse (LPN)/Treatment Nurse CC | Observed and confirmed topical medication use for resident R11 | |
| Licensed Practical Nurse (LPN) BB | Provided care to resident R11 and noted lotion kept at bedside | |
| Assistant Director of Nursing (ADON) | Interviewed regarding self-administration assessment and bathing concerns | |
| Director of Nursing (DON) | Interviewed regarding care plan compliance and expectations for nursing staff | |
| Social Worker | Interviewed regarding resident R64's concerns about bathing |
Inspection Report
Routine
Census: 109
Deficiencies: 4
Date: Dec 10, 2023
Visit Reason
A standard survey was conducted from December 8 through December 10, 2023, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for Harborview Health Center of Augusta.
Complaint Details
Complaint Intake Numbers GA00226201, GA00228506, GA00229153, and GA00238218 were unsubstantiated. Complaint Intake Numbers GA00236304 and GA00235741 were substantiated with no deficiencies.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to failure to assess resident self-administration of medications, failure to honor bathing preferences, failure to follow care plans regarding PEG tube verification, and improper medication administration via PEG tube.
Deficiencies (4)
Failed to assess one resident's ability to self-administer topical medication, risking medication error and effectiveness.
Failed to honor reasonable accommodations for bathing preferences for one resident, resulting in missed showers.
Failed to ensure care plan was followed for verifying PEG tube placement before medication administration for one resident.
Failed to properly utilize PEG tube for medication administration by not verifying placement and not allowing medications to enter via gravity.
Report Facts
Residents receiving topical medications: 20
Sampled Residents: 36
Residents receiving medications via PEG tube: 7
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Named in findings related to PEG tube medication administration and self-administration assessment |
| LPN BB | Licensed Practical Nurse | Provided care related to topical medication for resident R11 |
| LPN CC | LPN/Treatment Nurse | Confirmed topical medication use and placement for resident R11 |
| Assistant Director of Nursing | ADON | Interviewed regarding bathing concerns and medication self-administration assessment |
| Director of Nursing | DON | Interviewed regarding care plan adherence and medication administration expectations |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Dec 10, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident self-administration of medications, honoring resident preferences, care plan implementation, and proper use of feeding tubes at Harborview Health Center of Augusta.
Findings
The facility was found deficient in assessing a resident's ability to self-administer topical medications, honoring bathing preferences for a resident, following care plans related to PEG tube verification, and proper medication administration via PEG tube. Deficiencies were noted based on observations, interviews, and record reviews.
Deficiencies (4)
Failed to assess one resident's ability to self-administer topical medication, risking medication error and effectiveness.
Failed to honor reasonable accommodations for bathing preferences for one resident, resulting in missed showers.
Failed to ensure care plan was followed for verifying PEG tube placement before medication administration for one resident.
Failed to properly utilize PEG tube for medication administration, including not verifying placement and pushing medications via syringe instead of gravity.
Report Facts
Residents affected: 20
Residents affected: 36
Residents affected: 7
Date survey completed: Dec 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) AA | Named in medication administration and PEG tube placement verification findings | |
| Licensed Practical Nurse (LPN) BB | Provided care to resident with lotion kept at bedside | |
| Licensed Practical Nurse (LPN)/Treatment Nurse CC | Observed applying lotion and interacting with resident regarding topical medication | |
| Assistant Director of Nursing (ADON) | Interviewed regarding resident care plans, medication orders, and bathing concerns | |
| Director of Nursing (DON) | Interviewed regarding expectations for nursing staff compliance with care plans and medication administration | |
| Social Worker | Interviewed regarding resident concerns about bathing |
Inspection Report
Routine
Deficiencies: 4
Date: Dec 10, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident self-administration of medication, honoring resident preferences for bathing, adherence to care plans, and proper use of feeding tubes.
Findings
The facility was found deficient in assessing a resident's ability to self-administer topical medication, honoring a resident's bathing preferences, following care plans for PEG tube verification, and proper medication administration via PEG tube. These deficiencies posed minimal harm or potential for actual harm to a few residents.
Deficiencies (4)
Failed to assess one resident's ability to self-administer topical medication, risking medication error and altered effectiveness.
Failed to honor reasonable accommodations for bathing preferences for one resident, resulting in missed showers.
Failed to verify placement of PEG tube before medication administration as specified in the care plan for one resident.
Failed to properly utilize PEG tube by not allowing medications to enter via gravity and not verifying placement before administration.
Report Facts
Residents reviewed for self-administration assessment: 20
Residents sampled for bathing preference: 36
Residents reviewed for care plan adherence: 36
Residents receiving medications via PEG tube: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) AA | Named in medication administration observation and interview regarding PEG tube medication administration and self-administration lotion care | |
| Licensed Practical Nurse (LPN) BB | Provided care to resident's leg with lotion and interviewed about lotion use | |
| Licensed Practical Nurse (LPN)/Treatment Nurse CC | Observed and interviewed regarding lotion application and resident's self-administration | |
| Assistant Director of Nursing (ADON) | Interviewed regarding resident care plans, bathing concerns, and medication self-administration assessments | |
| Director of Nursing (DON) | Interviewed regarding expectations for nursing staff compliance with care plans and medication administration | |
| Social Worker | Interviewed regarding resident bathing concerns and follow-up procedures |
Inspection Report
Life Safety
Capacity: 120
Deficiencies: 0
Date: Dec 9, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 Edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Inspection Report
Deficiencies: 0
Date: Jul 27, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Harborview Health Center of Augusta, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 102
Deficiencies: 0
Date: Jul 27, 2022
Visit Reason
A revisit survey was conducted on 7/26/22 and 7/27/22 to verify correction of deficiencies cited during the 4/29/22 Recertification Survey.
Findings
All deficiencies cited as a result of the 4/29/22 Recertification Survey were found to be corrected.
Inspection Report
Life Safety
Census: 99
Capacity: 120
Deficiencies: 0
Date: May 4, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and related fire safety standards.
Findings
The facility was found in compliance with the requirements set forth in 42 CFR Subpart 483.90(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition. The Emergency Preparedness Program was also reviewed and found compliant with 42 CFR § 483.73.
Inspection Report
Renewal
Census: 101
Deficiencies: 3
Date: Apr 29, 2022
Visit Reason
The inspection was a Licensure Survey conducted from April 26, 2022 through April 29, 2022 to assess compliance with state regulations for licensure renewal.
Findings
The facility was found deficient in multiple areas including failure to provide routine dental services ensuring proper denture fit, inadequate infection prevention and control practices by housekeeping staff, and failure to maintain appropriate nursing care for a resident receiving enteral feedings by not elevating the head of the bed as ordered.
Deficiencies (3)
Failure to ensure Resident #52 received routine dental services to ensure dentures fit properly and were in good condition.
Failure to maintain an effective infection prevention and control program; housekeeping staff did not change gloves or perform hand hygiene between cleaning rooms, did not follow disinfectant application and contact time instructions, and reused cleaning cloths between rooms.
Failure to provide nursing care according to patient needs; Resident #290's head of bed was not elevated 30-45 degrees during enteral feeding as ordered.
Report Facts
Census: 101
Deficiency count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NN | Social Services Director | Interviewed regarding dental services and resident #52's denture issues |
| JJ | Housekeeper | Observed and interviewed regarding infection control deficiencies |
| KK | Housekeeping Manager | Interviewed regarding housekeeping policies and infection control |
| VV | Licensed Practical Nurse | Interviewed regarding nursing care and enteral feeding for resident #290 |
| DON | Director of Nursing | Interviewed regarding importance of head of bed elevation during enteral feeding |
| Registered Dietician | Interviewed regarding head of bed elevation during enteral feeding |
Inspection Report
Routine
Census: 101
Deficiencies: 6
Date: Apr 29, 2022
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding resident rights, care practices, infection control, and other regulatory requirements at Harborview Health Center of Augusta.
Findings
The facility was found deficient in multiple areas including failure to honor resident bathing preferences, failure to notify physicians of abnormal blood sugar levels, improper care of residents with feeding tubes, inadequate respiratory care related to oxygen humidification, failure to provide timely dental services, and deficiencies in infection prevention and control practices including housekeeping protocols.
Deficiencies (6)
Failure to ensure resident R#52 was provided showers according to preference; bed baths were given instead.
Failure to notify physician of blood sugar levels below 100 mg/dl or above 250 mg/dl for resident R#76 as ordered.
Failure to keep head of bed elevated 30-45 degrees during enteral feeding for resident R#290.
Failure to ensure humidification for tracheostomy mask oxygen therapy for resident R#35; humidifier bottle was empty.
Failure to provide routine dental services ensuring dentures fit properly for resident R#52.
Failure to maintain effective infection prevention and control program; housekeeping staff failed to change gloves and perform hand hygiene between rooms, did not follow disinfectant dwell times, and reused cleaning cloths between rooms.
Report Facts
Bed baths documented for resident R#52: 12
Blood sugar readings below 100 mg/dl for resident R#76: 41
Blood sugar readings above 250 mg/dl for resident R#76: 8
Census: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LL | Certified Nurse Aide (CNA) | Interviewed regarding resident R#52's shower schedule and care |
| MM | Certified Nurse Aide (CNA) | Interviewed regarding care provided to resident R#52 |
| XX | Licensed Practical Nurse (LPN) | Interviewed regarding notification of physician for blood sugar levels for resident R#76 |
| VV | Licensed Practical Nurse (LPN) | Observed and interviewed regarding enteral feeding care for resident R#290 |
| SS | Licensed Practical Nurse (LPN) | Interviewed regarding oxygen humidification for resident R#35 |
| ZZ | Physician | Attending physician for resident R#35 and R#76, interviewed about care and notification practices |
| YY | Respiratory Therapist | Interviewed regarding importance of oxygen humidification for resident R#35 |
| NN | Social Services Director | Interviewed regarding dental services for resident R#52 |
| JJ | Housekeeper | Observed and interviewed regarding housekeeping practices and infection control |
| KK | Housekeeping Manager | Interviewed regarding housekeeping protocols and infection control |
| DON | Director of Nursing | Interviewed regarding bathing preferences, blood sugar notification, and feeding tube care |
| Administrator | Interviewed regarding expectations for resident care and compliance | |
| SSD NN | Social Services Director | Interviewed regarding dental services scheduling and resident concerns |
| LPN CC | Licensed Practical Nurse | Observed connecting humidifier bottle for resident R#35 |
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