Bainbridge Landing Of Journey Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Bainbridge, Georgia.
- Location
- 1155 West College Street, Bainbridge, Georgia 39819
- CMS Provider Number
- 115324
- Inspections on file
- 17
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Bainbridge Landing Of Journey Llc during CMS and state inspections, most recent first.
An LPN administered a resident’s PRN Hydrocodone-Acetaminophen for chronic pain but failed to sign the narcotic proof-of-use form immediately afterward. Surveyors found one missing signature during cart review, and staff confirmed the medication had been given without being documented in the narcotic record.
Blood glucose strip vials in a medication cart were found without open dates. An LPN confirmed the omission and stated the strips depreciate after opening, while the DON and other LPNs stated the strips should be dated when opened because exposure to air can degrade them and lead to false blood sugar readings.
An infection control deficiency occurred when staff did not perform hand hygiene between glove changes during wound care for a resident with pressure ulcers and during suprapubic catheter care for a resident at risk for UTI and MASD. The WCN/IP also kept gloves in a pocket for use and an LPN changed gloves and cleaned a blood sugar machine without sanitizing hands. Staff and the DON confirmed hand hygiene was expected before and after glove use.
Dusty Air Filters in Resident Rooms: The facility failed to keep air filters in two resident rooms clean, with repeated observations showing the filters heavily coated with dust. The Maintenance Director confirmed the condition and stated the filters were cleaned monthly, but no complete documentation was provided to verify the scheduled cleaning, and the IP stated the Maintenance Director was responsible for keeping the filters clean.
Surveyors identified multiple sanitation and food safety issues, including severely rusted shelving used to store food, dirty air vents and walls, a gap under an exit door, and the use of a damaged paint brush for food preparation. Additionally, improper sanitizing procedures were observed at the three-compartment sink, and food items in the kitchenette refrigerator were found unlabeled and undated, with staff confirming lack of notification when food was brought in by family.
Surveyors found that multiple bedrooms and bathrooms had unsafe and poorly maintained conditions, including unstable sinks, holes in walls, and dirty or damaged surfaces. A resident expressed concern about the risk of injury due to the unstable bathroom fixtures, and both the Administrator and Maintenance Director confirmed the issues. The Maintenance Director reported that no repair requests had been received for these problems, despite routine rounds.
Surveyors found that several corridor sections, including areas near the dining room, public restroom, and nursing station, were missing required handrails on each side. Both the Administrator and Maintenance Director confirmed the absence of handrails in these locations, and the issue had not been previously identified. This deficiency has the potential to impact the safety of 25 residents.
A resident with multiple chronic conditions and moderate cognitive impairment was unable to leave his room or participate in preferred activities due to the lack of a portable oxygen tank, despite expressing a desire to be more active. Staff interviews confirmed that the resident's mobility was restricted by the current oxygen setup, and no clinical reason was identified to prevent the use of portable oxygen to support his participation in facility activities.
A resident with multiple medical conditions developed a stage III pressure ulcer and experienced significant weight loss, but the facility did not complete a comprehensive significant change assessment within the required 14-day period. Although these changes were discussed in daily clinical meetings attended by the MDSC and DON, the assessment was delayed due to staff workload.
A resident with Alzheimer's disease was documented in the MDS assessment as not receiving a mechanically altered diet, despite physician orders and staff interviews confirming the resident was on a mechanical soft, ground meat diet due to a mouth injury. The MDS Coordinator acknowledged the error, resulting in an inaccurate assessment.
Two residents with indwelling urinary catheters were observed with their catheter drainage bags uncovered and in direct contact with the floor, contrary to facility policy requiring bags to be kept off the floor and covered. An LPN confirmed that this practice did not follow infection control protocols and increased the risk of infection.
The facility failed to notify two residents of room changes, as required by policy. One resident, with minimal cognitive impairment, was moved three times without consent, while another's family was unaware of four room changes. Interviews confirmed the lack of documentation and notification.
Missing Narcotic Documentation After Administration
Penalty
Summary
The facility failed to ensure the Controlled Substances Proof of Use form was signed after narcotic administration for one resident receiving Hydrocodone-Acetaminophen 5-325 mg as needed for chronic pain syndrome. The resident had intact cognition with a BIMS score of 15, received PRN pain medication, and was identified as taking an opioid. The physician’s order directed that the medication be given every 6 hours as needed for pain. During observation of the 100 Hall medication cart, surveyors found the narcotics and narcotic book being checked and identified one missing signature on the Controlled Substances Proof of Use form. The form showed 14 tablets remaining for the resident’s Hydrocodone-Acetaminophen, while the blister pack had 13 tablets. An LPN present during the review confirmed she administered the narcotic tablet but did not sign that it had been administered. She stated she was distracted by a relative of another resident and forgot to sign after giving the medication. Facility staff and the DON stated that narcotic documentation should be completed immediately after administration. The DON explained that the controlled substance sheets protect from diversion or misappropriation and that delayed or missing documentation could create a discrepancy in the narcotic count. Other LPNs interviewed stated the narcotic book should be signed immediately after administration because another nurse could unknowingly give another dose, and the resident could receive an additional dose too soon.
Blood Glucose Strip Vials Stored Without Open Dates
Penalty
Summary
Two blood glucose strip vials in the top right drawer of the 100 hall medication cart were observed without open dates during a review of the cart. The facility’s policy titled, Medication Storage, stated medications housed on the premises would be stored in the pharmacy and/or medication rooms according to the manufacturer’s recommendations. During the observation, an LPN confirmed the two blood glucose vials had no open dates and stated there should be open dates because the strips depreciate after opening and no one would know when they were opened without one. The DON stated her expectation was that medications have open dates and that blood glucose strips have a shortened shelf life, so they should have an open date. She further stated that if the strips were used on residents, there would be inaccurate blood sugar readings, medication errors, and residents could be over medicated or under medicated. Additional LPN interviews stated the strips should have open dates when first opened because exposure to air can degrade them and lead to false blood sugar readings.
Failure to Perform Hand Hygiene Between Glove Changes During Wound and Catheter Care
Penalty
Summary
The facility failed to practice infection control protocol during wound care and catheter care when staff did not perform proper glove use and hand hygiene between glove changes. The facility’s policies stated that hand hygiene must be performed before donning gloves and immediately after removing gloves, and that gloves do not replace hand hygiene. The infection prevention and control program policy also stated the facility maintains an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. One resident was re-admitted with an open wound to the right hip and had unhealed pressure ulcers, including two stage 4 pressure ulcers present on admission. The resident’s care plan included enhanced barrier precautions related to pressure ulcer wounds, and physician orders directed wound treatment with cleansing, silver sulfadiazine, and dressing changes. During observed wound care, the WCN/IP placed gloves in her pocket, removed them from her pocket to use for care, and changed gloves without sanitizing or washing her hands between glove changes. Another resident had a suprapubic catheter for neurogenic bladder and was identified as at risk for UTI and moisture-associated skin damage. During observed catheter care, the WCN/IP removed the old dressing, disposed of it, then removed gloves from her pocket and put on the new pair without sanitizing her hands. A separate observation showed an LPN leaving a resident’s room, removing gloves, disposing of them at the nurses’ station, then donning a new pair of gloves and cleaning a blood sugar machine without hand sanitizing between glove changes. Staff interviews confirmed they did not sanitize hands between glove changes and stated this could cause cross contamination and infection.
Dusty Air Filters in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and safe environment by allowing air filters in two sampled resident rooms to remain heavily coated with dust. Review of the facility’s Safe and Homelike Environment Policy and Procedure stated that the facility would provide a safe, clean, comfortable, and homelike environment and that housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Observations in one resident room showed the air filter unit located under the window was heavily coated with dust on three separate occasions, and the same condition was observed in a second resident room on three separate occasions. During an interview and concurrent observation, the Maintenance Director confirmed that the air filters in the two rooms were excessively dusty, should not have been in that condition, and required cleaning. The Maintenance Director stated that air filters were cleaned monthly on the first of each month, but no complete documentation was provided to verify that the cleaning had been performed as scheduled. The Infection Preventionist stated that the Maintenance Director was responsible for ensuring that air filters were maintained in a clean condition.
Sanitation and Food Safety Deficiencies in Kitchen and Kitchenette
Penalty
Summary
Surveyors observed multiple sanitation and food safety deficiencies in the facility's kitchen and kitchenette. In the main kitchen, metal shelving units in the walk-in refrigerator and under the coffee machine were found to be severely rusted and flaking, with food items such as fruit, vegetables, and coffee supplies stored directly on them. A return air vent near the prep sink and the wall above the hanging pots and pans rack were covered in dirt, grease, and dust, while the wall near a light switch was visibly dirty. The outside exit door had a one-inch gap at its base, which could allow pests to enter, and the wooden screen door was left open during meal service. During food preparation, staff were seen using a paint brush with charred, curled bristles and a burned wooden handle to apply oil and butter to food items. The same brush was used for multiple purposes and was cleaned in the dishwasher between uses. Additionally, the three-compartment sink used for sanitizing pots and pans was found to have sanitizer levels at 700 PPM, exceeding the facility's policy range of 150-200 PPM. Large containers were not fully submerged in the sanitizing solution due to a leaking drain, leaving them improperly sanitized. In the kitchenette near the main nursing station, a refrigerator contained an open, unlabeled, and undated container of chocolate ice cream with whipped cream on top, as well as a Tupperware container labeled only with a resident's name but lacking a date or description of contents. The Director of Nursing confirmed that dietary staff were responsible for the refrigerator's condition and that the food had likely been brought in by a family member without notifying staff.
Unsafe and Unmaintained Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment in two of four areas, specifically the 100-hall and 300-hall, affecting multiple bedrooms and residents. In several bedrooms and shared bathrooms, sinks were found to be loosely fitted to the wall, with some leaning forward severely and inadequately supported by makeshift wooden posts. One bathroom had a hole in the wall behind the sink, and another bedroom wall had a large hole and extensive, discolored scrapes and gouges. Additionally, a bathroom door was noted to be discolored and dirty, and another wall between beds was sunken with severe discoloration from previous repairs. These conditions were confirmed by both the Administrator and Maintenance Director during interviews. A resident reported concerns about the safety of using the bathroom with a wheelchair, fearing that the unstable sink could fall if a supporting post was dislodged. The Maintenance Director stated that the facility used an electronic system (Tels) for repair requests, requiring staff to submit maintenance issues through this system. However, the Maintenance Director indicated that no requests for the noted repairs had been received and that routine rounds had not identified these issues. The Administrator and Maintenance Director both verified the environmental deficiencies during interviews.
Corridor Handrails Not Installed in Multiple Areas
Penalty
Summary
Surveyors observed that four sections of corridors in the facility were not equipped with handrails on each side, as required. Specifically, a 21-foot section in front of the dining room, an 8-foot section near the public restroom, a 13-foot section across from the main nursing station leading to the 300 unit, and an 8-foot section across from the nursing station leading to the 100 unit were all found to be lacking handrails. These findings were confirmed through interviews with both the Administrator and the Maintenance Director, who acknowledged the absence of handrails in the identified areas and indicated that this issue had not been previously reported or addressed. The lack of handrails in these corridors has the potential to affect the safety of 25 residents, as noted in the report.
Failure to Accommodate Resident's Mobility Needs Due to Oxygen Equipment
Penalty
Summary
A deficiency was identified when the facility failed to reasonably accommodate the needs and preferences of a resident with multiple medical conditions, including acute respiratory failure with hypoxia, COPD, diabetes, heart failure, and depression. The resident, who was moderately cognitively impaired and used a wheelchair for mobility, expressed a preference for being out of his room and participating in activities. However, he reported being unable to leave his room due to the inconvenience of moving his oxygen concentrator, leading to repeated complaints of boredom and isolation during multiple observations and interviews. Staff interviews revealed that the resident previously had a portable oxygen tank, which allowed for greater mobility, but this was discontinued due to concerns about the resident not notifying staff when tanks were empty. Despite a physician's order for the resident to participate in activities as tolerated, and no clinical reason preventing the use of a portable tank, the resident remained confined to his room. The activity director and DON acknowledged the resident's limited participation in activities and the impact of the oxygen equipment on his mobility.
Failure to Complete Timely Significant Change Assessment for Resident with Pressure Ulcer and Weight Loss
Penalty
Summary
The facility failed to complete a comprehensive significant change assessment within 14 days for a resident who experienced both a pressure ulcer and significant weight loss. The resident, who had medical diagnoses including morbid obesity, hemiplegia, depression, and dysphagia, was admitted without pressure ulcers but was at risk for them. Over time, the resident developed an open area on the coccyx and later had a stage III pressure ulcer and deep tissue injuries on both heels. The resident also experienced a weight loss of 35 pounds. Despite these significant changes, the required comprehensive assessment was not completed in a timely manner as mandated by facility policy. Interviews with the MDS Coordinator and the Director of Nursing confirmed that significant changes in condition, such as drastic weight loss or the development of stage III or IV pressure ulcers, should trigger a comprehensive assessment within 14 days. Both staff members acknowledged that these changes were discussed in daily clinical meetings, but the assessment was not completed as required. The MDS Coordinator admitted to not resetting the assessment date due to being busy, and confirmed that the 14-day window for the assessment had passed.
Inaccurate MDS Assessment for Resident on Mechanically Altered Diet
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident. According to the facility's policy, residents are to receive assessments that accurately reflect their status at the time of assessment, conducted by qualified staff. For this resident, who had a diagnosis of Alzheimer's disease, the quarterly MDS assessment indicated that the resident was not on a mechanically altered diet. However, a review of the resident's diet orders and communication forms showed that the resident had been placed on a mechanical soft, ground meat diet due to a mouth injury, and this order was still in effect at the time of the MDS assessment. Interviews with facility staff, including the Dietary Manager and Nurse Practitioner, confirmed that the resident was receiving a mechanically altered diet and had not been reassessed to change this order. The MDS Coordinator acknowledged that the MDS Section K should have indicated the use of a mechanically altered diet but was not marked accordingly. This discrepancy between the resident's actual diet and what was documented in the MDS assessment resulted in an inaccurate assessment for the resident.
Failure to Maintain Catheter Drainage Bags Off Floor and Covered
Penalty
Summary
Surveyors identified that the facility failed to maintain proper infection prevention and control practices for residents with indwelling urinary catheters. Specifically, two residents with catheters were observed with their catheter drainage bags not covered in privacy storage bags and in direct contact with the floor. Facility policy requires that catheter drainage bags be kept off the floor and covered with a privacy storage bag to prevent infection. During observations, both residents' catheter bags were found lying on the floor without the required cover, and staff confirmed that this was not in accordance with infection control protocols. One resident had a history of cellulitis of the groin, acute and chronic respiratory failure, and was on hospice care, while the other had polyneuropathy, diabetes mellitus, and a urethral stricture, and was on enhanced barrier infection precautions due to a suprapubic catheter. Both residents' care plans indicated the use of indwelling catheters and the need for infection prevention measures. Staff interviews confirmed that the observed practices did not align with facility policy and increased the risk of infection.
Failure to Notify Residents of Room Changes
Penalty
Summary
The facility failed to honor the residents' rights to receive written notice before a room change, as outlined in their policy. Two residents, R3 and R7, were moved to different rooms without prior notification or documentation of the changes in their medical records. R3, who has a BIMS score indicating little to no cognitive impairment, reported being moved three times without being asked for consent. Similarly, R7's family member reported four room changes without being notified, only discovering the changes during visits. Interviews with the Social Services Director and the Administrator confirmed the lack of documentation and notification regarding the room changes. The Social Services Director stated that residents are supposed to be consulted before a move, and the responsible party should be notified, but this process was not followed. The Administrator acknowledged the absence of documentation in the residents' records, which is required when room changes occur.
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Surveyors found that clean linens and personal clothing were stored and staged in close proximity to the dirty laundry area, with an open door between the clean and soiled sides and all washer and dryer doors open. Clean resident clothes, unlabeled garments, and bagged items were placed next to dryers and directly in front of the dirty linen room, and dirty barrels had to be pushed past racks of clean clothing to reach the washers, contrary to facility policies requiring separation of clean and soiled linens. Environmental staff believed keeping doors open and covering dirty barrels reduced infection spread, while the Environmental Services Director, IP nurse, and Administrator acknowledged that the dirty room door should be closed, linens should not be on dirty barrels, and clean resident clothing should not be stored in that location.
A resident with a suprapubic catheter, colostomy, sacral wound, and dependence on staff for bathing and hygiene was care planned for Enhanced Barrier Precautions (EBP), including use of PPE during high-contact care. During observed catheter care and a bed bath, a CNA wore only gloves and did not don a gown, despite EBP signage and a star posted on the door and PPE supplies available outside the room. In interviews, the CNA admitted forgetting to wear a gown and not recognizing additional required actions, while the IP nurse and DON confirmed that staff had been educated that gowns and gloves are required for high-contact care involving indwelling devices and wounds under the facility’s EBP policy.
A resident with multiple neurologic and psychiatric diagnoses, intact cognition, and unilateral functional limitations was found with an open box of lubricant eye drops stored at the bedside without any documented assessment for self-administration or prescriber’s order for self-administration or bedside storage, contrary to facility policy. Observations on multiple days confirmed the eye drops remained at the bedside, while staff interviews showed that CNAs and the IP recognized that residents were generally not to self-administer medications and that bedside medications required assessment and orders. The Administrator confirmed that the resident should not have had eye drops in the room and that residents with bedside medications are typically assessed for self-administration, and staff acknowledged that unsecured eye drops at the bedside could be accessed or ingested by other residents and cause harm.
The facility failed to maintain a safe, clean environment when multiple ceiling tiles throughout the building, including above a resident’s bed, near the nurses’ station, in a glass day room above a resident’s chair, and in a main hall, were observed with brown circular stains, bulging, and a white moldy substance. The Maintenance Director confirmed the stained and bulging tiles, acknowledged the risk that tiles above a resident’s bed could fall, and attributed the condition to rain-related roof leaks. The Administrator also confirmed that roof leaks and recent rainfall caused the brownish stains despite her reported daily rounds.
A resident with severe cognitive impairment, on hospice and fully dependent for ADLs, was sexually abused when another cognitively impaired male resident with a long-standing history of sexually inappropriate behavior toward female residents entered her room and placed his hand inside her pants. The abusing resident had multiple dementia and psychiatric diagnoses, was care planned for sexually inappropriate behaviors with prior documented incidents, and was on psychotropic medication for OCD-related sexual obsession. Despite these known risks and existing care plan interventions, he was able to access the female resident’s room and make inappropriate physical contact, and the facility’s investigation substantiated the abuse.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans for two residents. One resident was receiving an antipsychotic (Haloperidol) for schizophrenia with associated behavior and side-effect monitoring orders, but there was no corresponding care plan addressing antipsychotic use or its indication. Another resident had an indwelling Foley catheter for neurogenic bladder related to prostate cancer, with goals to prevent catheter-related trauma; however, the care plan omitted key interventions such as balloon volume parameters and use of a leg strap or securement device, despite physician orders requiring a leg strap and observations showing the catheter positioned under the leg without securement. An MDS coordinator and the administrator acknowledged that required interventions and standard catheter care components were missing from the care plans.
A resident with a history of resistiveness to care and noncompliance with the non‑smoking policy had a comprehensive care plan that was not updated to reflect multiple interventions implemented in response to repeated smoking and vaping violations. Although the care plan noted the need for supervision while smoking and review of the smoking policy, it did not include measures such as daily room searches for smoking materials, added smoke detection in the room, relocation closer to the nurses’ station, q2h visual rounds for smoke, post‑outing nursing checks, initiation of a PAR process for vaping, or issuance of a discharge notice. Facility forms showed inconsistent documentation of daily room searches and incomplete IDT documentation on the PAR tracking, despite multiple documented episodes of policy violations and removal of vaping devices.
A cognitively intact but physically impaired resident with a history of noncompliance with the facility’s non‑smoking policy repeatedly smoked and vaped in his room while keeping multiple vape devices and other items at bedside. The facility’s Smoking Policy required that non‑compliant smokers have daily documented searches and be prohibited from keeping smoking materials in their rooms, yet monitoring forms showed many days without documented searches, Patient at Risk tracking was incomplete, and staff acknowledged that daily room checks and frequent rounds were not consistently performed. Multiple staff, including a CNA, social worker, Infection Preventionist, MDS coordinator, Activities Director, and the Administrator, reported ongoing violations and repeated discovery of vape devices in the resident’s room, including during surveyor observations, demonstrating that the environment was not maintained free from accident hazards and that required supervision and monitoring were not reliably implemented.
Surveyors found that a treatment cart containing topical medications was left unlocked and unattended in a hall across from a resident’s room after wound care was completed by an LPN. The facility’s policy requires that medication carts and supplies be locked or attended and accessible only to licensed or otherwise authorized staff. During interviews, the LPN confirmed the cart had been left unlocked and unattended, the IP LPN confirmed the LPN’s report that the cart was left unlocked, and the Administrator stated that all medications, including topical medications, were expected to be locked when not in sight of authorized staff.
The facility failed to implement its infection prevention and control program by not operationalizing a documented Legionella water management plan despite having a written policy, and by not fully implementing Enhanced Barrier Precautions (EBP) for residents with indwelling devices and other risks. A resident with an indwelling urinary catheter had no EBP care plan or orders, no EBP signage, and staff providing catheter care wore only gloves without gowns, while multiple staff members reported not knowing what EBP was or misidentified who should be on EBP. Another resident receiving tube feeding had care initiated by an LPN who wore gloves but no gown and repeatedly touched her hair with the same gloved hands before handling the feeding tube and equipment, later acknowledging she should have changed gloves and was unaware of EBP requirements, even though other clinical staff stated gowns and gloves should be used for feeding tube care. A resident on isolation for C. diff had a door sign indicating isolation but no instructions for visitors on required PPE or to seek staff guidance, and the IP confirmed there was no system to direct visitors about precautions, contributing to the overall infection control deficiency.
Failure to Maintain Separation of Clean and Soiled Laundry
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to separation of clean and soiled linens. Facility policies titled “Infection Prevention and Control Program” and “Handling Soiled Linens” required that clean linen always be separated from soiled linen. During an observation of the laundry area, all washer and dryer doors were open in the clean linen area. Clean linens, including sheets, towels, blankets, and washcloths, were folded on a table to the left of the washer and dryer room. On the right side of the room, next to the dryers and directly in front of the open door to the dirty laundry room, there were residents’ clean clothes on a rack, piles of folded clean clothes to be hung, a rack of unlabeled clothes, and a bag of unlabeled clothes. Dirty laundry barrels had to be pushed past the clean clothing on the racks to reach the washers, placing soiled items in close proximity to clean items despite policy requirements for separation. Environmental staff working in the laundry stated they believed they were reducing the spread of infection by keeping all doors open, covering dirty barrels, and circulating air, and they explained that the uncovered rack and bagged clothes near the dirty area were no-name clothes sometimes distributed to residents in need. They also stated that the rack of clean personal resident clothing parked in front of the open dirty linen room door was awaiting distribution by a staff member who worked only at night. The Environmental Services Director reported that the door to the dirty side of the laundry should always be closed and that no linen should be on top of dirty barrels. The Infection Preventionist nurse, when shown pictures and concerns about cross-contamination, confirmed there was a problem in the laundry but stated she had not been aware of it previously. The Administrator stated that residents’ clothes should not be stored where they were observed and should be handed out immediately once clean, and that she expected the laundry to be organized to prevent cross-contamination between dirty and clean clothes.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its Enhanced Barrier Precautions (EBP) policy for the use of personal protective equipment (PPE) during high-contact care. The facility’s EBP policy, updated February 2025, requires gowns and gloves for residents with wounds and/or indwelling medical devices, including urinary catheters and ostomies, when staff perform high-contact activities such as bathing, dressing, toileting, hygiene, and catheter care. The policy also directs that gowns and gloves be made available near or outside the resident’s room and that EBP be implemented for residents with indwelling devices or wounds, even if they are not known to be infected or colonized with a multidrug-resistant organism. The resident involved had a suprapubic catheter, colostomy, sacral wound, and neurogenic bladder and bowel, and was care planned for EBP implementation during catheter and skin care. The resident was cognitively intact but dependent on staff for bathing, dressing, toileting, hygiene, bed mobility, and transfers, and used an indwelling catheter and ostomy. During an observation, a CNA provided suprapubic catheter care and a bed bath to this resident while only wearing gloves, despite EBP signage and a star posted on the door and PPE supplies available outside the room. The CNA did not don a gown and was unable to identify any additional actions needed before care until prompted about the EBP signage, at which point he acknowledged he should have worn a gown but forgot. In a subsequent interview, the IP nurse and DON confirmed that staff had been educated that gowns are required during high-contact care for residents with catheters, colostomies, and other devices, and that the posted signage and star were intended to alert staff to the need for enhanced PPE use.
Failure to Assess and Obtain Orders for Self-Administration and Bedside Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for self-administration of medications and bedside medication storage for one resident. The facility’s policies require that residents who wish to self-administer medications must be assessed by the interdisciplinary team for cognitive, physical, and visual ability, and that a prescriber’s order for self-administration and bedside storage must be present in the medical record and reflected on the MAR and medication label. For the resident in question, who had diagnoses including cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, hemiplegia and hemiparesis, speech and language deficits, and cerebral atherosclerosis, the EHR showed no assessment for self-administration and no physician order for self-administration or bedside storage, despite active ophthalmic medication orders. The resident’s MDS documented intact cognition with a BIMS score of 15, use of corrective lenses, and functional limitations in range of motion on one side of both upper and lower extremities. Surveyor observations on two consecutive days found an open box of lubricant eye drops on the resident’s bedside table. Staff interviews revealed inconsistent understanding and enforcement of the facility’s policies. A CNA stated that residents did not self-administer medications and that only nurses administered them, but also reported that when she previously reported the eye drops, she was told the resident could have them because he was independent. The Infection Preventionist acknowledged the resident had an order for eye drops and believed he obtained them from the VA, and stated he should not have the lubricant eye drops because they were a hazard for other people. The Administrator confirmed that typically a resident with medications at the bedside should be assessed for self-administration and stated the resident should not have eye drops in his room. The report notes that unsecured medications at the bedside had the potential to cause adverse reactions if accessed or ingested by other residents.
Failure to Maintain Safe and Clean Ceiling Surfaces Throughout Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment as required by its Maintenance Service policy, which assigns the Maintenance Department responsibility for keeping the building in good repair and free from hazards. Surveyors observed multiple stained and damaged ceiling tiles in several areas of the facility, including near the nurses' station, in a resident bedroom (room [ROOM NUMBER]A), in the glass day room, and in the middle of the east hall. On several occasions, ceiling tiles near the nurses' station were noted to have tannish-brown circular stains of varying sizes, and at one point a white, moldy substance was observed on a ceiling tile in that same area. In room [ROOM NUMBER]A, surveyors observed brown rings roughly 16 inches in diameter on ceiling tiles located directly above a resident’s bed, with the Maintenance Director later confirming that these tiles were stained, bulging, and at risk of falling on the resident. Additional observations in the glass day room identified two stained ceiling tiles above a resident’s chair, each with brown circular stains approximately three inches in diameter. In the east hall, a ceiling tile with a brown circular stain approximately 10 inches in diameter was also documented. The Maintenance Director and the Administrator both acknowledged that the stains and damage were related to roof leaks associated with recent rainfall, and the Administrator confirmed awareness of roof leaks that had previously been repaired and that the brownish stains were due to recent rain.
Failure to Prevent Sexual Abuse of a Cognitively Impaired Resident by Another Resident
Penalty
Summary
The facility failed to protect a dependent, cognitively impaired resident (R113) from sexual abuse by another resident (R12). R113 had severe cognitive impairment with a BIMS score of 5, was on hospice care, and was fully dependent for toileting, bathing, dressing, footwear, and personal hygiene. On the day of the incident, a CNA observed R12 in R113’s room with his right hand inside R113’s pants while she was seated in a geriatric chair. Staff witness statements and nursing progress notes documented that R12 was found in R113’s room with his hand in her pants, and the facility’s investigation substantiated that R12 touched R113 inappropriately. R12 also had severe cognitive impairment with a BIMS score of 4 and multiple psychiatric and dementia-related diagnoses, including vascular dementia with mood disturbance, Alzheimer’s disease, major depressive disorder, obsessive-compulsive personality disorder, unspecified psychosis, and unspecified mood affective disorder. He required extensive physical assistance, used a manual wheelchair, and was fully dependent for toileting, bathing, lower body dressing, and footwear. R12’s care plan, in place since 2017, identified him as having sexually verbally and physically inappropriate behavior, including documented prior incidents in which he inappropriately touched or attempted to touch female residents. His care plan included interventions such as discussing his behavior when reasonable, explaining that it was inappropriate, intervening to protect others, diverting his attention, and removing him from situations as needed, as well as monitoring and recording occurrences of target behaviors such as sexual aggression toward others. Despite this known history of sexually inappropriate behavior toward female residents and the presence of care plan interventions, R12 was able to enter R113’s room and place his hand inside her pants. The Administrator confirmed that the CNA reported finding R12 in R113’s room with his hand in her pants while R113 was in her wheelchair, and that the facility’s investigation substantiated the abuse allegation. The facility’s abuse policy stated that it would not condone resident abuse by anyone, including other residents, and defined sexual abuse to include sexual harassment, sexual coercion, or sexual assault. The occurrence of this incident demonstrated that the facility did not effectively prevent sexual abuse of R113 by another resident, despite R12’s documented behavioral history and existing care plan.
Failure to Develop and Implement Complete Care Plans for Antipsychotic Use and Foley Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for identified resident needs, as required by its Comprehensive Care Plan policy. The policy states that care plans must address all needs identified in the comprehensive assessment, including medical, nursing, mental, and psychosocial needs, and must be developed within seven days after completion of the comprehensive MDS assessment. It also requires that all triggered Care Area Assessments (CAAs) and other factors identified by the IDT or resident preferences be incorporated into the plan of care. For one resident, R44, the clinical record showed physician orders for Haloperidol 10 mg by mouth twice daily for schizophrenia, along with orders for behavior monitoring and psychiatric medication side effect monitoring. Despite these orders, the resident’s care plan dated 03/11/2026 did not include any care plan addressing antipsychotic medication use or its indication. The MDS Coordinator stated that all residents receiving antipsychotic treatment should have a comprehensive care plan in place beginning with the date the medication was originally ordered, and upon review of the record confirmed that such a care plan was not present for this resident at the time of the survey. For another resident, R3, the care plan dated 03/13/2026 identified a problem of an indwelling catheter secondary to neurogenic bladder related to prostate cancer, with goals including remaining free from catheter-related trauma. The listed interventions included positioning the catheter bag and tubing below bladder level, monitoring and documenting intake and output per policy, and monitoring for pain, discomfort, and signs and symptoms of UTI. However, the care plan did not address the amount of water in the catheter balloon, use of a leg strap or securement device, or other securement measures. Physician orders specified checking a leg strap every shift and documented that the resident was admitted with an 18F catheter attached to a bedside drainage bag, but observations showed the Foley catheter positioned under the resident’s leg without a leg strap or securement device on two occasions, and a CNA reported being unaware that a leg strap was required. The MDS Coordinator confirmed that these ordered interventions were missing from the care plan.
Failure to Revise Care Plan for Ongoing Smoking Policy Noncompliance
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan to reflect current interventions implemented in response to ongoing noncompliance with the facility’s non‑smoking policy. The facility’s policy requires that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and that it include measurable objectives, timeframes, and alternative interventions as needed, with qualified staff notified when changes are made. The resident’s care plan included a focus on resistiveness to care and noncompliance with smoking, noting that the resident continued to go outside beyond facility property to smoke, and an intervention to review the smoking policy with the resident. Another care plan focus identified the resident as a smoker requiring supervision while smoking, with interventions stating the resident required supervision while smoking and that the charge nurse should be notified if a smoking policy violation was suspected. Despite repeated and ongoing noncompliance with the non‑smoking policy, the care plan was not revised to include additional interventions that were actually implemented. These unreflected interventions included daily room searches for smoking paraphernalia, placement of a smoke detector in the resident’s room, relocation of the resident’s room closer to the nursing station, every‑two‑hour visual rounds to check for smoke, nursing checks upon return from outings, initiation of a Patient at Risk (PAR) process for vaping noncompliance, and issuance of a 30‑day discharge notice for repeated violations of the non‑smoking policy. Documentation on the Smoking Materials Monitoring Form showed initials on selected days only, indicating daily room searches were not consistently completed and documented for the entire month. The PAR Smoking Tracking form documented multiple observations of vaping in the room, repeated room checks, removal of vapor devices, and the resident’s refusal to comply with facility policies, with later weeks lacking IDT signatures and documentation, while the PAR Grid showed multiple prior entries for violating the non‑smoking policy.
Failure to Control Smoking and Vaping Hazards for a Noncompliant Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision for a resident with a known history of noncompliance with the facility’s non‑smoking policy. The facility’s Smoking Policy requires that residents not be allowed to keep cigarettes, cigars, pipes, matches, or lighters in their possession or rooms, and that non‑compliant smokers receive daily searches with documentation, while compliant smokers receive weekly searches. The policy also requires incident reports and review in a “Patients at Risk” process whenever smoking materials are found. Despite these written procedures, the resident’s Smoking Materials Monitoring Form for April showed multiple days without documented searches, indicating that required daily room searches were not consistently completed or recorded. The resident at issue was cognitively intact, with a BIMS score of 15, and had significant physical impairments including hemiplegia and hemiparesis on the left side, use of a manual wheelchair, and other neurologic and psychiatric diagnoses such as cerebral aneurysm, cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, and speech and language deficits. The care plan identified the resident as resistive to care and noncompliant with smoking, noting that he continued to go outside beyond facility property to smoke, and also identified him as a smoker requiring supervision while smoking. Progress notes and Patient at Risk documentation showed a pattern of repeated violations of the non‑smoking policy, including multiple instances of vaping and smoking in his room, with staff repeatedly finding vape devices and other smoking paraphernalia in his possession and in his room. Throughout the period reviewed, staff observations and interviews confirmed ongoing noncompliance with the smoking policy and inconsistent implementation of the facility’s own interventions. Staff documented several occasions when the resident was observed vaping or smoking in his room, including in the presence of a state surveyor, and room searches revealed multiple vape devices hidden under the sheets. Staff interviews indicated that daily room checks were not always performed due to competing demands, that logs of every‑two‑hour rounds were not maintained, and that there was confusion or inconsistency regarding whether the resident could keep items such as air freshener at bedside. The social worker, Infection Preventionist, MDS coordinator, Activities Director, CNA, and Administrator all acknowledged that the resident’s room had to be searched for cigarettes and vaping paraphernalia and that prohibited items were repeatedly found, while documentation showed gaps in the required daily searches and incomplete follow‑through on the Patient at Risk tracking process. These actions and inactions resulted in the environment not being kept free from accident hazards as required by the facility’s policy and regulatory standards. The deficiency is further supported by the facility’s own records showing repeated entries on the Patient at Risk grid for violations of the non‑smoking policy over an extended period, as well as narrative notes describing the resident’s statements that he would continue to vape in his room and would simply obtain new devices if they were confiscated. Despite the known pattern of behavior and the facility’s policy requiring close supervision, daily searches, and thorough documentation for non‑compliant smokers, the monitoring forms and staff interviews demonstrate that these measures were not consistently carried out. The presence of multiple vape devices and cans of air freshener at the bedside during surveyor observations, along with staff acknowledgment that room checks were missed and that logs of frequent rounds were not kept, illustrate the facility’s failure to effectively implement its own safety procedures to prevent accident hazards related to smoking and vaping in the resident’s room.
Unlocked and Unattended Treatment Cart with Topical Medications
Penalty
Summary
Surveyors identified a deficiency related to medication storage when a treatment cart containing topical medications was left unlocked and unattended in a hall. The facility’s policy titled “Medication Storage in the Facility,” effective 10/01/2025, states that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that medication rooms, carts, and supplies are to be locked or attended by authorized personnel. During an observation on 04/29/2026 at 9:35 AM, after wound care was provided to resident R3 by the wound care LPN, the treatment cart was observed left in the [NAME] hall across from R3’s room, unlocked and unattended for 30 minutes. In an interview, the wound care LPN confirmed that the treatment cart had been left unlocked and unattended. The Infection Preventionist LPN later confirmed that the wound care nurse told her the cart was left unlocked, and the Administrator stated that her expectation was that all medications, including topical medications, be locked when not in sight of a licensed nurse or authorized person. This deficient practice occurred in a facility with a census of 94 residents and involved the failure to follow the facility’s own policy requiring that medication carts be locked or attended by authorized personnel, resulting in unsecured access to topical medications on the treatment cart.
Failure to Implement Legionella Water Management and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to provide and implement an infection prevention and control program, including a documented water management plan for Legionella and other waterborne pathogens, and a fully implemented Enhanced Barrier Precautions (EBP) program. The Administrator stated there was no Legionella water program in place, and the Maintenance Supervisor reported he was unaware of the requirement for such a program. This was despite the existence of a written Legionella Water Management Program policy, revised in September 2022, which described the need for an interdisciplinary water management team, detailed water system diagrams, identification of risk areas and situations for Legionella growth, control measures, monitoring systems, and annual review. Interviews confirmed that the expectation was that the facility would be conducting this water program, but it was not being done. The facility also failed to implement EBP for residents with indwelling medical devices and other risk factors, as required by its own policy. One resident with Alzheimer’s disease, urinary obstruction, and emphysema had an indwelling urinary catheter documented in the care plan and physician orders, but the care plan did not address EBP related to the catheter, and there was no order for EBP in the record. During catheter-related care, a CNA wore gloves but did not wear a gown, and there was no EBP signage or PPE setup at the room. Multiple staff members, including CNAs and a housekeeper who regularly worked on the resident’s hallway, reported they did not know what EBP was or incorrectly associated EBP only with residents on Transmission-Based Precautions. The DON acknowledged that an attempt to roll out EBP months earlier had not been completed, and that expected signage and PPE caddies for EBP were not fully in place. Additional infection control lapses were observed during tube feeding care and contact isolation. A resident receiving continuous tube feeding had a care plan and physician’s order for enteral nutrition, and an LPN initiated the feeding while wearing gloves but no gown. During the procedure, the LPN repeatedly touched her hair with the same gloved hands and then handled the feeding tube, pump, and syringe used to inject air and check residuals, only removing gloves and using hand sanitizer at the end. The LPN later acknowledged she should have changed gloves after touching her hair and stated she did not know what EBP was or that a gown was required for feeding tube care, while another LPN and the IP stated that EBP with gown and gloves should be used for feeding tube care and that staff should not touch their hair during care without changing gloves and performing hand hygiene. For a resident with a positive urine culture and a subsequent positive C. difficile culture who was on isolation, the door sign indicated isolation but did not provide instructions for visitors on required precautions or direct them to staff for guidance. The IP confirmed there was no system to direct visitors about PPE use for residents on contact isolation and acknowledged that visitors would not know to wear PPE if it was simply present in or on the door of the room. Overall, the survey findings show that the facility did not operationalize its written Legionella water management policy and did not consistently apply its EBP policy for residents with indwelling devices or wounds. Staff interviews and observations demonstrated a lack of knowledge and implementation of EBP, incomplete use of PPE during high-contact care activities such as catheter care and tube feeding, and unclear isolation signage that did not instruct visitors on appropriate precautions. These combined inactions and omissions in policy implementation, staff education, and practice led to the cited infection prevention and control deficiency.
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