Inspection Reports for Harborview Health Center of Augusta
3618 J DEWEY GRAY CIRCLE, GA, 30909
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Life Safety
Deficiencies: 5
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.
Severity Breakdown
D: 4
F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Exit sign on the 300 Hall was not working when tested. | D |
| Fire alarm panel had trouble codes. | F |
| Sprinkler head in the kitchen freezer was not installed correctly and was leaking. | D |
| Light fixtures were missing globes, including a light in the pantry on 300 Hall. | D |
| Oxygen storage rooms on 300 and 500 Hall were missing empty storage signage. | D |
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
Annual Inspection
Deficiencies: 0
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
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.
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.
Complaint Details
Complaint Intake Numbers GA00254503, GA00254478, and GA00254832 were substantiated with deficiencies cited. Multiple other complaint intake numbers were investigated and found unsubstantiated.
Severity Breakdown
SS= D: 5
SS= E: 2
SS= F: 2
SS= G: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| 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. | SS= D |
| Failed to update care plan interventions to prevent pressure ulcers for a resident who developed three pressure ulcers after hospital readmission. | SS= D |
| Failed to ensure preventative measures to avoid pressure ulcers for a resident at risk who acquired three pressure ulcers after readmission. | SS= D |
| Failed to arrange podiatry services for two residents reviewed for activities of daily living. | SS= D |
| Failed to maintain and store respiratory equipment appropriately for a resident with a tracheostomy, including dirty oxygen concentrator and outdated suction tubing. | SS= D |
| Failed to manage pain adequately for a resident by ensuring availability of fentanyl patches, consistent pain assessment, and physician notification of missed medication. | SS= G |
| Failed to ensure medications were available for two residents, resulting in missed doses of multiple medications including pain and cardiac drugs. | SS= E |
| Failed to ensure insulin pens and vials had pharmacy labels, were dated when opened, and were discarded after expiration on two medication carts. | SS= E |
| Failed to ensure all items in kitchen refrigerator and freezer were sealed, labeled, and dated, risking foodborne illness for residents. | SS= F |
| 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. | SS= D |
| 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. | SS= F |
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
Abbreviated Survey
Census: 104
Deficiencies: 0
Oct 4, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted at Harborview Healthcare Augusta to investigate Complaint Intake Numbers GA00250996 and GA00251078.
Findings
Complaint Intake Number GA00250996 was found unsubstantiated with no deficiency cited. Complaint Intake Number GA00251078 was substantiated with no deficiency cited.
Complaint Details
Complaint Intake Number GA00250996 was unsubstantiated. Complaint Intake Number GA00251078 was substantiated. No deficiencies were cited for either complaint.
Inspection Report
Deficiencies: 0
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
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.
Findings
All previously cited deficiencies from the prior Complaint Investigation survey were found to be corrected during this revisit survey.
Complaint Details
This visit was a follow-up to a Complaint Investigation survey concluded on April 25, 2024, verifying correction of deficiencies.
Inspection Report
Renewal
Deficiencies: 4
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)
| Description |
|---|
| 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
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.
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.
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.
Severity Breakdown
SS= D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure personal information was kept confidential for two residents; medication cards were left unattended on top of the medication cart. | SS= D |
| Failed to ensure grievance procedures were followed for one resident; grievance form lacked follow-up and resolution documentation. | SS= D |
| Failed to ensure a dressing was maintained for a stage IV sacral pressure ulcer for one resident; wound was exposed to urine and feces. | SS= D |
| Failed to ensure clinical records were complete and accurately documented for three residents; missing medication administration documentation and incomplete care documentation. | SS= D |
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
Deficiencies: 0
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
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
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)
| Description |
|---|
| 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
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.
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.
Complaint Details
Complaint Intake Numbers GA00226201, GA00228506, GA00229153, and GA00238218 were unsubstantiated. Complaint Intake Numbers GA00236304 and GA00235741 were substantiated with no deficiencies.
Severity Breakdown
D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to assess one resident's ability to self-administer topical medication, risking medication error and effectiveness. | D |
| Failed to honor reasonable accommodations for bathing preferences for one resident, resulting in missed showers. | D |
| Failed to ensure care plan was followed for verifying PEG tube placement before medication administration for one resident. | D |
| Failed to properly utilize PEG tube for medication administration by not verifying placement and not allowing medications to enter via gravity. | D |
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
Life Safety
Capacity: 120
Deficiencies: 0
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
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
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
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
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.
Severity Breakdown
D: 2
E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure Resident #52 received routine dental services to ensure dentures fit properly and were in good condition. | D |
| 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. | E |
| 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. | D |
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 |
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