Inspection Reports for
Lakepoint Augusta LLC

The visit was complaint-related, involving investigations #144546 and 144836. The facility was found deficient in pressure ulcer care and infection control practices.

The facility failed to provide necessary pressure ulcer care for one resident, including failure to reposition the resident for over three hours and 23 minutes and failure to apply physician-ordered dressing. Additionally, the facility failed to establish an antibiotic stewardship program with proper monitoring of antibiotic use.

The facility has developed and implemented a facility-wide system to assure correction and continued compliance with regulations. Education and ongoing monitoring by the Interdisciplinary Team and nursing staff are planned to ensure adherence to care plans and medication administration policies.

Complaint investigation #142825 focused on medication errors where staff administered medications to the wrong resident. The error was substantiated by observation, interviews, and record review.

The facility failed to ensure that one resident received medications as ordered by the physician when staff administered medications intended for another resident. The medication error was reported immediately by staff, and the resident remained alert and oriented after the incident.

The complaint investigation numbers were 140849 and 140513. The resident was found with a trash bag over their head and a drawstring around their neck, indicating a suicide attempt. The facility failed to follow the care plan to prevent access to plastic bags. The resident was later stabilized and not at risk for further harm.

The facility failed to provide planned interventions to ensure the safety of a resident with a history of suicidal ideation, who was found with a trash bag over their head and a drawstring wrapped around their neck. Despite care plans to prevent access to plastic bags, the resident had access to them, indicating a failure to follow the plan of care.

All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date, with completion dates noted for each.

The inspection was conducted as a resurvey with investigation of complaint #127070.

The facility was found deficient in multiple areas including inaccurate functional capacity screening, incomplete negotiated service agreements, failure to monitor outside service providers, inadequate provision of health care services, unsafe food storage, unlocked storage of hygiene supplies accessible to cognitively impaired residents, unlocked laundry room with chemicals not secured, and unsanitary dietary areas.

The facility developed and implemented corrective actions including staff in-service training, random checks by management, replacement and repair of furniture and equipment, and ongoing monitoring by the Quality Assurance Performance Improvement Committee to ensure compliance with regulations.

The inspection included complaint investigations #130532 and #134551.

The facility was found deficient in maintaining a safe, clean, and comfortable environment, completing significant change assessments, revising care plans, providing individualized toileting programs, respiratory care, and proper garbage disposal. Multiple deficiencies were noted including unsanitary conditions, failure to complete required assessments and care plan revisions, inadequate respiratory equipment handling, and improper refuse disposal.

The survey found the most serious deficiencies to be a 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 11/22/2018.

The facility developed and implemented corrective actions addressing multiple deficiencies including pacemaker monitoring, care plan revisions, Foley catheter care, respiratory distress monitoring, and timely response to call lights.

The inspection was triggered by complaint investigations #132473, 131671, 132572, and 132580.

The facility failed to develop and implement comprehensive care plans for residents, including failure to monitor pacemakers and oxygen administration. There were deficiencies in care plan timing and revision, quality of care related to pacemaker monitoring, catheter care, oxygen saturation monitoring, and sufficient nursing staff to meet residents' needs in a timely manner.

The survey found the most serious deficiency to be a 'F' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective September 21, 2018.

The inspection was triggered by complaint investigations #129899, #120621, #121065, and #121402.

The facility failed to review and revise residents' care plans to instruct staff in individualized care needs, failed to provide adequate assistance with hygiene and bathing, failed to ensure residents received appropriate supervision and assistive devices to prevent accidents, and failed to develop individualized toileting plans to promote continence and prevent urinary tract infections.

The facility developed and implemented a facility-wide system to assure correction and continued compliance with regulations, including staff education on fall interventions, urinary incontinence protocols, oral health care, bathing, and perineal care policies. The Director of Nursing or designee will monitor compliance and review results quarterly with the Quality Assurance Performance Improvement Committee.

The survey found the most serious deficiency to be an "E" level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective June 30, 2018.

All previously cited deficiencies related to various regulatory requirements were corrected as of 07/12/2017, with no uncorrected deficiencies noted at the time of this revisit.

The report shows that the deficiencies previously cited under regulation numbers 28-39-158(g) and 26-40-304 (c)(1)(a)(b)(c) were corrected as of the revisit date 07/12/2017.

The facility has developed and implemented a facility-wide system to assure correction and continued compliance with regulations. Specific corrective actions include staff education, policy reviews, implementation of new forms, and ongoing monitoring by the Director of Nursing and Quality Assurance Performance Improvement Committee.

The facility developed and implemented a system to assure correction and continued compliance with regulations, including re-education of dietary staff on kitchen sanitation and safety, discarding compromised equipment, repairing flooring, and implementing revised cleaning lists with ongoing audits and reviews.

The visit included complaint investigations #114552 and 116508. Immediate jeopardy was identified related to inadequate supervision leading to resident elopement. The facility abated the immediate jeopardy on 6/15/17 by revising policies and re-educating staff on elopement response.

The facility was found deficient in completing comprehensive assessments, ensuring resident safety from elopement, posting nurse staffing information, maintaining sanitary food preparation and storage, infection control practices, environmental cleanliness, and governance policies.

The facility was found to be out of substantial compliance with participation requirements, with deficiencies constituting immediate jeopardy from May 26, 2017 through June 15, 2017. Due to the severity and history of noncompliance, enforcement remedies including denial of payment for new admissions were imposed.

The facility failed to maintain sanitary food preparation conditions, with multiple areas of grime and dirt accumulation in kitchen equipment and surfaces. Additionally, the flooring and carpet in the kitchen and common areas were stained, cracked, or damaged, indicating poor maintenance and cleanliness.

The revisit report confirms that all previously cited deficiencies identified by regulation numbers 483.20(g)-(j), 483.20(d)(3), 483.10(k), 483.25(c), and 483.25(h) were corrected as of 09/15/2016.

The facility identified multiple deficiencies related to MDS coordination, care plan accuracy, pressure ulcer prevention, and resident environment safety. Corrective actions include staff training, policy reviews, audits, and disciplinary measures.

The facility failed to accurately code residents' status on MDS assessments, revise care plans with current pressure ulcer treatments, implement effective pressure ulcer prevention and treatment measures, and ensure safe resident transfers using gait belts as care planned. Resident #8 had two unstageable pressure ulcers that were not properly managed, and staff failed to use gait belts during transfers despite care plan instructions.

This enforcement action is based on deficiencies found on the current survey and a complaint survey conducted on December 15, 2015.

The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, specifically related to pressure ulcers (F314). Due to the facility's history of noncompliance, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.

This enforcement action is based on deficiencies found in the current survey and a complaint survey conducted on December 15, 2015.

The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, specifically related to pressure ulcers (F314). Due to the facility's history of noncompliance, no opportunity to correct deficiencies was given before enforcement remedies were imposed, including denial of payment for new Medicare and Medicaid admissions.

Plan of Correction is in response to deficiencies cited from the Lakepoint complaint inspection dated 07/07/2016.

The facility developed and implemented a facility-wide system to assure correction and continued compliance with regulations. Specific corrective actions include mandatory in-services for licensed staff on care plans, bladder assessments, and professional standards of care, along with ongoing audits and reviews by the Director of Nursing or designee.

Complaint investigation #102037 focused on care plan revisions, urinary incontinence, and medication management issues.

The facility failed to review and revise care plans for residents to include swallow precautions and individualized toileting plans, failed to ensure residents remained as free from urinary incontinence as possible, and failed to monitor bowel movements adequately for residents receiving stool softeners and laxatives.

The survey found the most serious deficiencies to be 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.

The report confirms that the previously cited deficiency with ID Prefix F0323 related to regulation 483.25(h) was corrected as of 2016-01-13. No other deficiencies or uncorrected issues are noted.

This Plan of Correction addresses deficiencies cited during a complaint survey at Lakepoint Augusta.

The facility identified issues related to resident safety during sit-to-stand transfers and has implemented a facility-wide system to assure correction and continued compliance, including staff training, therapy evaluations, and ongoing audits.

Complaint investigation #94214 focused on inadequate supervision and failure to use safety straps during mechanical lift transfers, leading to a resident fall and injury. Staff reported residents refusing straps but did not notify nurses. Training was provided but not consistently followed.

The facility failed to apply safety straps on the sit to stand lift for 4 sampled residents at risk for falls, resulting in one resident falling from the lift and fracturing both hips. Staff inconsistently used safety straps despite training and facility policies requiring their use. Several staff admitted to not using straps if residents refused or did not want them, and refusals were not consistently reported to nursing staff.

The survey found the most serious deficiency in the facility to be a 'G' level. As a result, enforcement remedies including denial of payment for new Medicare and Medicaid admissions will be imposed until substantial compliance is achieved.

The report confirms that the previously cited deficiency under regulation 28-39-158(a) was corrected as of 12/04/2015. No other deficiencies or uncorrected issues are noted.

The facility was cited for multiple deficiencies including failure to provide planned activities, inadequate housekeeping and maintenance, failure to review and revise care plans, insufficient monitoring of skin conditions and pressure ulcer prevention, unsanitary food storage and preparation, and inadequate infection control practices. The facility outlined corrective actions and measures to prevent recurrence for each deficiency.

The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective December 4, 2015.

The inspection was triggered by a complaint investigation #85906.

The facility was found deficient in multiple areas including failure to provide adequate activities for residents, inadequate housekeeping and maintenance services, failure to review and revise care plans for residents with incontinence and pressure ulcers, failure to monitor skin conditions adequately, failure to prevent pressure ulcers, unsanitary food storage and preparation conditions, and inadequate infection control practices related to cleaning and linen handling.

The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required and enforcement remedies were recommended.

The report shows that previously identified deficiencies under regulations 28-39-158(g) and 26-40-304(c)(1)(a)(b)(c) were corrected as of 08/27/2014.

The facility has developed and implemented a system to assure correction and continued compliance with regulations, including staff training on abuse and neglect policies, equipment maintenance, and cleaning procedures.

The facility failed to investigate and report an allegation of resident abuse, maintain housekeeping and maintenance services resulting in stained and frayed carpeting, prepare and serve food under sanitary conditions, and maintain food preparation equipment in safe operating condition.

The facility failed to store food at proper temperatures as recommended by manufacturers, risking food borne illness, and failed to maintain clean and sanitary conditions in common areas, including stained and discolored carpets.

The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective August 27, 2014.

The report confirms that deficiencies previously cited under regulations 483.20(d), 483.20(k)(1), and 483.25(h) have been corrected as of 04/02/2014.

The findings represent the results of complaint investigations numbered 73458, 73348, and 73349. The complaint was substantiated as the facility failed to prevent a resident fall due to lack of foot pedals on the wheelchair during staff transport.

The facility failed to develop a comprehensive care plan including the use of foot pedals on a resident's wheelchair during staff transport, resulting in a fall and injury. The facility also failed to provide appropriate assistive devices to prevent the fall, causing the resident to sustain skin tears and bruising.

This Plan of Correction addresses deficiencies cited during a complaint investigation survey at LakePoint Augusta.

The facility developed and implemented a system to assure correction and continued compliance with regulations, focusing on accurate completion of resident care plans and ensuring residents have necessary assistance devices to prevent accidents.

The survey found isolated 'D' level deficiencies with no harm but potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required to address these deficiencies.

The facility developed and implemented a system to assure correction and continued compliance with regulations. Specific deficiencies related to quality of care, resident repositioning, and proper cleaning/sanitizing of dining room tables were addressed with staff training and ongoing monitoring.

The report shows that all previously identified deficiencies with ID prefixes F0309, F0314, and F0323 were corrected as of 05/10/2013.

The visit was triggered by complaint investigation #64044. The findings included substantiated failures in care and safety practices related to resident positioning, pressure sore prevention, and environmental safety.

The facility failed to provide necessary care and services to maintain residents' highest well-being, including failure to provide proper positioning devices and interventions for residents with dementia, inadequate repositioning to prevent pressure sores, and failure to ensure a safe environment free of accident hazards, specifically related to unsafe sanitizing practices in the dining room.

The facility developed and implemented a system to assure correction and continued compliance with regulations, including reviewing policies on food storage and labeling, and addressing carpet cleaning and maintenance issues.

The facility has developed and implemented a facility-wide system to assure correction and continued compliance with regulations. Staff education and ongoing monitoring by the Interdisciplinary Team (IDT) are part of the corrective actions.

The facility developed and implemented a system to assure correction and continued compliance with regulations, including re-education of licensed nursing staff on wound management, antibiotic stewardship, infection prevention, and visual monitoring policies.