Inspection Reports for
Lakepoint Augusta LLC

The investigation was triggered by a complaint regarding Resident 1 eloping from the facility on 06/14/25. The complaint was substantiated with findings of inadequate supervision and improper response to door alarms.

The facility failed to ensure an environment free from accident hazards by not providing adequate supervision and not responding appropriately to a door alarm, resulting in Resident 1 eloping and being outside unsupervised for 44 minutes with injuries. The facility implemented corrective actions including reeducation of staff and placement of a WanderGuard.

The facility failed to complete accurate Minimum Data Sets (MDS) for multiple residents, failed to develop comprehensive care plans for several residents, did not maintain proper infection control practices including Enhanced Barrier Precautions, failed to maintain accurate narcotic drug records, and failed to submit accurate staffing data to CMS. Additional issues included failure to clean CPAP masks, improper catheter care, and lack of policy for pet vaccinations.

The complaint investigation revealed that Resident 1 fell from a Hoyer lift due to improper use of a hygiene sling and lack of staff training. The fall caused injuries requiring hospital treatment. The facility lacked specific training and assessment related to the hygiene sling use prior to the fall.

The facility failed to ensure staff used the proper Hoyer lift transfer sling for Resident 1, causing the resident to fall and require hospital treatment. Additionally, the facility failed to ensure competent nursing staff were available to assist residents using the hygiene sling during transfers.

The complaint investigation was triggered by family concerns about neglect and verbal abuse by CNA M towards resident R1. The allegations included unsafe transfers without mechanical lift use, verbal threats involving references to 'Samurai' and threats of bodily harm, and failure of staff to report these incidents. The facility investigated, suspended, and terminated CNA M. Education and corrective actions were implemented.

The facility failed to ensure resident R1 was free from neglect and verbal/mental abuse. Staff attempted unsafe transfers without using the care planned mechanical lift, resulting in physical harm and verbal threats by CNA M. The facility also failed to report these incidents timely. The baseline care plan was found to be ineffective and incorrectly coded regarding transfer interventions.

The facility had multiple deficiencies including failure to ensure resident privacy during cares, inaccurate resident assessments, inadequate care plan revisions, improper pressure ulcer care, insufficient catheter care, lack of control and reconciliation of controlled medications, improper food sanitation practices, improper garbage disposal, and unsafe kitchen maintenance.

The facility failed to properly revise care plans to address residents' fears and restorative needs, did not provide adequate assistance with personal hygiene and restorative services, failed to ensure safe use of assistive devices and call light accessibility, and did not provide adequate supervision during showers leading to a resident fall. Additionally, the facility failed to provide consistent cueing and assistance to maintain weight for a resident.

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 nurses station visual monitoring.

The visit was complaint-related, triggered by complaints #144546 and #144836. The findings substantiated failures in pressure ulcer care and infection control.

The facility failed to provide necessary pressure ulcer care for one resident, resulting in inadequate repositioning and failure to apply physician-ordered dressings. Additionally, the facility lacked an effective antibiotic stewardship program to monitor antibiotic use among residents.

The complaint investigation #142825 found that on June 25, 2019, staff administered medications to the wrong resident. The error was reported immediately by the staff involved. The resident was alert and oriented after the incident. Facility policy requires accurate medication administration and immediate reporting of errors.

The facility failed to ensure that one resident received medications as ordered by the physician when staff administered medications intended for another resident. This resulted in a significant medication error involving multiple medications without physician orders for the affected resident.

The facility has developed and implemented a system to assure correction and continued compliance with regulations. Interdisciplinary Team and nursing staff have been educated on interventions to ensure adherence to residents' care plans, with ongoing monitoring planned for three months.

The investigation was triggered by complaints #140849 and #140513. The resident had a history of mental health issues and suicidal ideation. The facility failed to prevent access to plastic bags despite care plan interventions, resulting in a near-suicide event. The resident was stabilized and no further suicidal ideation was noted at the time of the survey.

The facility failed to provide planned interventions for one resident with behaviors to ensure safety. Specifically, the facility did not follow the care plan to prevent access to plastic bags for a resident with a history of suicidal ideation, which resulted in an incident where the resident placed a trash bag over their head with a drawstring around their neck.

The inspection was conducted as a resurvey with investigation of complaint #127070 involving concerns about resident care, service agreements, health care coordination, and facility conditions.

The facility was found deficient in multiple areas including inaccurate functional capacity screening, incomplete negotiated service agreements, failure to monitor outside service providers, inadequate health care services coordination, unsafe food storage, unlocked storage of chemicals and supplies, and unsanitary dietary and laundry areas.

The facility has developed and implemented corrective actions including staff in-service training, environmental cleaning improvements, and monitoring procedures to ensure compliance with regulations. Actions will be reviewed quarterly by the Quality Assurance Performance Improvement Committee.

The survey found a most serious deficiency at level 'F', 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 inspection was triggered by complaints related to housekeeping, resident care, and facility maintenance issues.

The facility failed to maintain a safe, clean, and comfortable environment, failed to complete significant change MDS assessments for residents with changes in condition, failed to revise care plans including individualized toileting plans, failed to provide appropriate respiratory care, and failed to properly dispose of garbage and refuse.

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 numbered 132473, 131671, 132572, and 132580.

The facility failed to develop and implement comprehensive care plans for residents, ensure timely review and revision of care plans, maintain quality of care including pacemaker monitoring and catheter care, provide adequate respiratory care including oxygen saturation monitoring, and failed to maintain sufficient nursing staff to meet residents' needs in a timely manner.

The survey found a most serious deficiency at level 'F', indicating no actual harm but potential for more than minimal harm without 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 on individualized care needs, failed to provide adequate assistance with hygiene and bathing, failed to ensure accident-free environment and supervision for a high fall risk resident, and failed to develop individualized toileting plans and provide appropriate perineal care to prevent urinary tract infections.

The facility developed and implemented a system to assure correction and continued compliance with regulations. The plan includes staff education on fall interventions, urinary incontinence protocols, oral health care, bathing policies, and perineal care, with ongoing monitoring and review by the Quality Assurance Performance Improvement Committee.

The survey found a most serious deficiency at an "E" level, indicating no actual harm but 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.

The facility has developed and implemented corrective actions for multiple deficiencies including MDS assessment accuracy, elopement policy, nurse staffing documentation, kitchen sanitation, and cleaning procedures for medical equipment and resident rooms. Ongoing monitoring and quarterly reviews by the Quality Assurance Performance Improvement Committee are planned.

The report documents that previously reported deficiencies identified by regulation numbers 28-39-158(g) and 26-40-304 (c)(1)(a)(b)(c) have been corrected as of the revisit date.

The facility developed and implemented a system to assure correction and continued compliance. Specific corrective actions include 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 facility was found to have deficiencies constituting immediate jeopardy from May 26, 2017 through June 15, 2017, with a history of noncompliance from a prior survey on August 16, 2016. Enforcement remedies including denial of payment for new admissions effective July 12, 2017, and recommendation for termination of provider agreement if substantial compliance is not achieved by December 21, 2017, were imposed.

The inspection included complaint investigations #114552 and #116508.

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

The facility failed to maintain sanitary conditions in food preparation and storage areas, including grime and stains on kitchen equipment and surfaces. Additionally, the facility did not maintain flooring and carpet areas in a clean and sanitary manner, with multiple areas of discoloration, stains, and damage observed.

All deficiencies previously reported on the CMS-2567 were corrected as of 09/15/2016, with no uncorrected deficiencies noted at the time of this revisit.

The facility identified deficiencies related to MDS coordination, care plan accuracy, pressure ulcer prevention, and resident safety regarding accident hazards and supervision. Corrective actions include staff training, policy reviews, ongoing monitoring, and disciplinary measures.

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 repeated noncompliance, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.

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 repeated noncompliance, the facility was denied payment for new Medicare and Medicaid admissions effective September 5, 2016, until substantial compliance is achieved.

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 transfers using gait belts as care planned.

All previously cited deficiencies identified by regulation numbers 483.20(d)(3), 483.10(k)(2), 483.25(d), and 483.25(l) were corrected as of the revisit date.

Complaint investigation #102037 focused on failures in care plan revisions and individualized care for residents, including toileting and medication management.

The facility failed to review and revise individualized care plans for eating and toileting for two residents, and failed to develop and implement individualized toileting plans to maintain continence. Additionally, the facility failed to monitor bowel movements and manage medications properly for one resident, resulting in unnecessary medication use.

The survey found the most serious deficiencies to be 'D' level, indicating no actual harm but 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 6, 2016.

This Plan of Correction is related to deficiencies cited from a complaint investigation identified as Lakepoint complaint 07072016.

The facility developed and implemented a system to assure correction and continued compliance with regulations. Specific deficiencies involved care plan accuracy, bladder assessments, and adherence to professional standards of care including medication administration and bowel movement monitoring.

The revisit confirmed that the previously cited deficiency under regulation 483.25(h) was corrected as of 2016-01-13. No other deficiencies or uncorrected issues were noted.

The facility identified issues related to resident safety during transfers, specifically with the use of sit-to-stand lifts. Corrective actions include staff training, therapy evaluations, and ongoing audits to ensure compliance and resident safety.

The investigation was triggered by complaint #94214 concerning inadequate supervision and safety device use during mechanical lift transfers.

The facility failed to apply safety straps on the sit to stand lift for four sampled residents, resulting in a resident falling and fracturing both hips. Staff often did not use or inform residents about the safety straps, and some residents refused the straps without proper documentation or nurse notification.

The report documents that the deficiency identified under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 12/04/2015.

The facility was found deficient in multiple areas including failure to provide planned activities, inadequate housekeeping and maintenance, failure to revise care plans, improper monitoring of skin conditions and pressure ulcers, unsanitary food storage and preparation, and inadequate infection control practices.

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 December 4, 2015.

The inspection was triggered by complaint investigation #85906.

The facility failed to provide adequate activities for a cognitively impaired resident, maintain housekeeping and maintenance services, review and revise care plans for residents with incontinence and pressure ulcers, monitor skin conditions adequately, prevent pressure ulcers, maintain sanitary food preparation and storage, and ensure proper infection control and cleaning procedures.

The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm, and not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The report confirms that the deficiencies previously reported under regulations 28-39-158(g) and 26-40-304(c)(1)(a)(b)(c) were corrected as of the revisit date.

The facility developed and implemented a system to assure correction and continued compliance. Specific corrective actions include staff training on food storage and labeling, professional carpet cleaning, and ongoing monitoring by designated staff.

The facility has developed and implemented a system to assure correction and continued compliance with regulations. Specific deficiencies addressed include policies on abuse and neglect, carpet cleaning and maintenance, equipment inspection and repair, with assigned staff responsible for ongoing monitoring.

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

The survey found widespread 'F' level deficiencies 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 based on the credible allegation of compliance.

The facility failed to store food at proper temperatures as recommended by manufacturers, risking food borne illness. Additionally, the facility did not maintain clean and sanitary conditions in common resident living areas, with stained and discolored carpets observed.

The report shows that previously identified deficiencies under regulations 483.20(d), 483.20(k)(1), and 483.25(h) were corrected as of the revisit date.

The visit was triggered by complaint investigations #73458, 73348, and 73349. The complaint was substantiated as the facility failed to prevent a resident fall related to wheelchair transport safety.

The facility failed to develop and implement a comprehensive care plan including the use of assistive devices such as foot pedals on a wheelchair to prevent falls. One resident fell from a wheelchair due to lack of foot pedals during staff transport, resulting in skin tears and bruising.

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 addressed include quality of care related to positioning and range of motion, resident repositioning to promote skin integrity, and proper cleaning/sanitizing of dining room tables.

The visit was triggered by complaint investigation #64044. The findings represent the results of this complaint investigation combined with a health resurvey.

The facility failed to provide necessary care and services to maintain residents' highest well-being, including proper positioning devices and interventions, adequate repositioning to prevent pressure sores, and ensuring a safe environment free of accident hazards during dining.

The facility has developed and implemented a system to assure correction and continued compliance with regulations. Staff have been educated on interventions to ensure adherence to residents' care plans, with ongoing monitoring planned.

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