Resorts of Augsburg

In the surveyor’s words

From the most serious findings on record at Resorts of Augsburg, in the surveyor’s own words.

• Actual harm, isolatedF697Apr 18, 2024

  Based on medical record review, other pertinent documentation, and staff interviews, it was determined that the facility failed to provide pain medication to Resident #17 who complained of pain and had a suspected fracture. Failure of the facility to administer pain medication resulted in harm to Resident #17 who remained in prolonged pain. This was evident for 1 out of 3 residents reviewed for pain during the survey The findings include: Review of Resident #17's medical record on 04/10/2024 at 2:00 PM revealed that Resident #17 was admitted to the facility in July 2021 with a diagnosis that included Dementia. […]

• No harm, potential for more than minimal, widespreadF880Dec 10, 2025

  Based on observation and interview with facility staff, it was determined that the facility failed to maintain an effective infection control program. Specifically, the facility failed to: 1) follow infection control practices consistent with accepted standards of practice, 2) prevent oxygen tubing from resting on the floor, 3) review and revise infection control policies and procedures annually, and 4) provide required follow-up care for a resident with a major infection. This was evident for 1 out of 4 nursing units reviewed, one of three residents reviewed for oxygen therapy (Resident #6), five of five facility policies reviewed, and one of one resident (Resident #89) reviewed for Transmission-Based Precautions during the facility's recertification survey. […]

• No harm, potential for more than minimal, patternF686Jul 24, 2026

  Based on record review and interviews, the facility failed to timely implement treatment recommendations for wound management and apply pressure-relieving devices as ordered. This was evident for 3 (Resident #11, #18, and #7) of 3 residents reviewed for wounds during the complaint survey. The findings include:According to the Centers for Disease Control (CDC), pressure ulcers (bed sores, pressure sores, or decubitus ulcers) are wounds from unrelieved pressure on the skin, per the CDC. They are staged by severity: Stage 1 is persistent skin redness; Stage 2 is partial thickness loss (abrasion, blister, shallow crater); Stage 3 is full thickness loss exposing subcutaneous tissue (deep crater); and Stage 4 is full thickness loss exposing muscle or bone. […]

• No harm, potential for more than minimal, patternF730Dec 10, 2025

  Based on review of employee files and interviews with facility staff, it was determined that the facility staff failed to conduct required performance reviews of Geriatric Nursing Assistants (GNAs) at least once every 12 months. This was found to be evident for 8 (GNA #36, GNA #40, GNA #41, GNA #33, GNA #42, GNA #34, GNA #37, GNA #38) out of 10 GNA employee files reviewed during the Sufficient and Competent Nurse Staffing facility task for the facility's recertification survey. The findings include:Performance reviews are to be completed for each GNA at least every 12 months to identify specific, in-service education based on the outcome of those individual performance reviews. […]

• No harm, potential for more than minimal, patternF756Dec 10, 2025

  Based on review of medical records and interview with facility staff, it was determined that the facility failed to 1) develop policies and procedures that address the time frames for the steps in the MRR process and the steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident 2) ensure a pharmacist conducted a complete MRR, at least monthly 3) ensure monthly Medication Regimen Reviews were completed by the facility's providers, 4) respond to recommendations made by consulting pharmacists in a timely manner, and 5) identify instances where the medication indication was inaccurately documented. […]