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
- 15
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Bainbridge Landing Of Journey Llc during CMS and state inspections, most recent first.
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.
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.
Latest citations in Georgia
The facility failed to follow its abuse investigation policy when responding to an allegation that a male resident wandered into a female shared room, allegedly sat on a resident’s bed, inappropriately touched her leg, stared at another resident, and opened the bathroom door to watch a third resident brushing her teeth. The allegation was reported by a cognitively intact resident and involved residents with varying levels of cognitive impairment. The investigation, conducted by the Administrator and former DON, relied only on interviews with a RN and a CNA, did not obtain required written, signed, and dated witness statements, and did not include interviews with other residents to assess their sense of safety. Despite these omissions and incomplete documentation, the facility’s final report concluded the allegation was unsubstantiated.
A resident with protein calorie malnutrition and a terminal prognosis was admitted on hospice with corresponding physician orders and a care plan, but hospice services were not coded on either the admission or quarterly MDS assessments. The MDS Coordinator and two MDS LPNs confirmed that, despite the resident receiving hospice care, Section O of both MDS assessments incorrectly indicated the resident was not on hospice, which the Administrator and DON acknowledged resulted in inaccurate MDS data.
Surveyors found that PTAC unit filters in two resident rooms on one hallway were not maintained free of visible grey, fuzzy debris, despite facility policy requiring regular inspection and cleaning or replacement at least every three months. Across multiple observations on different days, the condition of the dirty filters remained unchanged. The Maintenance Director reported he is responsible for monthly cleaning and checks, including spot checks and inspections in construction areas, and did not dispute the observed dust accumulation when shown. The Administrator confirmed that maintenance staff are responsible for monthly PTAC filter cleaning as part of preventative maintenance and acknowledged that this issue could negatively affect residents’ health and well-being.
A resident with intact cognition and known skin integrity risks reported being left on a bedpan for an extended period and not being adequately cleaned by a CNA. The following shift, another CNA found the resident on soiled linens with a blister on the left upper thigh but did not report this new skin issue to the charge nurse or DON. Subsequent documentation showed development of an open area on the thigh associated with pain, and later NP evaluation identified a larger wound requiring sharp excisional debridement. These events show failure to provide adequate incontinent care and to promptly assess and report a new wound, contrary to the facility’s abuse/neglect prevention policy and CNA responsibilities.
A cognitively intact resident with skin-related diagnoses reported delayed and inadequate incontinent care after using a bedpan, describing prolonged waits for staff response and feeling not properly cleaned by a CNA. The next morning, another CNA found feces-soiled linen and a blister on the resident’s left upper thigh, later documented as a new open area. The resident texted the Administrator stating that a CNA had left feces on her and that she had developed a painful blister, but the Administrator did not report this allegation of neglect to the State Survey Agency as required by facility policy.
A resident with lymphedema and identified risk for pressure ulcers developed a new open wound on the upper thigh, documented by a NP with specific wound measurements. Although the existing care plan included interventions to observe and document skin changes, the care plan was not updated to include this new wound. The Wound Care Nurse and the resident confirmed the wound location, while the MDS Coordinator reported not receiving recent weekly wound reports and only recently learning of the wound. The MDS Coordinator confirmed that the care plan had not been revised in real time as required by facility procedures, resulting in a failure to implement care plan interventions for the newly developed pressure ulcer.
The facility did not complete a required Georgia Criminal History Check System (GCHEXS) fingerprint background check for a CNA, as identified during review of ten employee files with a census of eighty residents. The facility’s abuse-prevention policy required criminal background checks for all employment candidates, but there was no documentation of a fingerprint records check for this CNA. The HR manager, who is responsible for background and fingerprint checks and maintaining employee files, confirmed that the GCHEXS fingerprint check had not been conducted, resulting in a deficiency under F-Tag 600.
Surveyors found that four of six resident shower rooms were not kept free of hazards or adequately cleaned. On one floor, razors were on the floor, dirty gloves and a comb were on a shower bed, floors were stained, an opened gallon of bath soap and a bottle of chemical-resistant spray were present, and a razor and hair clippers were in a bag on the floor along with a shower cap and toothbrush. On other floors, surveyors observed multiple opened containers of skin and hair cleaner, conditioner, and skin ointment, along with a strong urine odor. Unit managers and the Environmental Senior Director stated that CNAs were responsible for cleaning after each resident and that environmental services cleaned shower rooms daily, and acknowledged that items should not be left on the floor and that product containers should be closed.
Surveyors found that staff did not follow standard and transmission-based precautions when handling ice on two floors. On one floor, the ice scoop cover on top of the ice machine had visible black specks near the end of the scoop used to dispense ice. On another floor, the ice scoop was observed submerged in ice and water inside the cooler used to serve residents, despite the unit manager acknowledging that the scoop should not be left in the cooler. The Maintenance Director reported that maintenance cleaned and checked ice machines regularly, while nursing staff were responsible for cleaning scoops and covers. The SDC/Infection Control nurse stated that all staff had been in-serviced on hand hygiene and ice scoop protocol, including that scoops should be stored in a holder after use and never left in the ice.
A resident with multiple serious conditions, moderate cognitive impairment, and total dependence for ADLs was placed in bed with side rails intended to assist with positioning, despite the MDS indicating no bed rail use. Facility records showed no evidence of safe rail spacing or regular inspection of the bed and rails. The assigned CNA, who came on duty late in the evening, last saw the resident around the start of the shift and did not check on him again for several hours, relying on the resident to use a call light. In the early morning, the CNA and an RN found the resident partially out of bed, entrapped in the half side rail, requiring multiple staff to free and reposition him. The resident was unresponsive except for moaning, with altered mental status and respiratory failure documented by EMS and the ER, and later expired at the hospital. The facility’s failure to provide required monitoring and to ensure safe side rail use resulted in neglect and Immediate Jeopardy.
Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of an allegation of sexual abuse in accordance with its policy titled “Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating.” The policy required that all allegations be thoroughly investigated, including reviewing documentation and evidence, interviewing any witnesses, interviewing staff on all shifts who had contact with the resident, and completely documenting the investigation, with written, signed, and dated witness statements. A facility-reported incident documented that a male resident was wandering into a female three-bed room, allegedly inappropriately touching one resident, staring at another for a length of time, and then opening the bathroom door and staring at a third female resident while she was brushing her teeth. The allegation was initially reported by a cognitively intact resident (BIMS score 15) and involved another resident with moderate cognitive impairment (BIMS score 8) and a resident with severe cognitive impairment (BIMS score 99). The Administrator reported that the investigation of this incident was conducted by the former DON and herself after the allegation was reported by a RN. She stated that this was not the first time the alleged male resident had wandered into other residents’ rooms and described the allegation as the male resident entering a resident’s room, sitting on the resident’s bed, and allegedly touching the resident’s leg. Staff interviews for the investigation were limited to the RN and a CNA, and the Administrator acknowledged that no written witness statements were obtained, contrary to facility policy. She also confirmed that no additional residents were interviewed to assess their sense of safety following the incident. The facility’s final investigation report concluded that the allegation was unsubstantiated, despite the lack of comprehensive interviews, written statements, and full documentation required by the facility’s abuse investigation policy.
Failure to Accurately Code Hospice Services on MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of the Minimum Data Set (MDS) for a resident receiving hospice services. The facility’s policy on Certification of Accuracy of the MDS requires that appropriate health professionals correctly document residents’ medical, functional, and psychosocial problems using the Resident Assessment Instrument. The resident in question was admitted with diagnoses including protein calorie malnutrition and had a care plan dated 01/09/2026 indicating a terminal prognosis and admission to hospice, with a goal to honor advance directives and provide comfort with dignity. Physician’s orders dated 12/09/2025 also included an order to admit the resident to hospice. Despite this, review of the admission MDS and a subsequent quarterly MDS showed that hospice services were not coded in Section O (Special Treatments, Procedures and Programs), even though both assessments documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. Interviews with the MDS Coordinator and two MDS LPNs confirmed that the resident had been on hospice since admission and that both the admission and quarterly MDS assessments were incorrectly coded as not on hospice. The MDS Coordinator acknowledged that the MDS should present an accurate clinical picture for a given period and stated that this was a clerical error, resulting in CMS not receiving correct hospice coding for the resident. The Administrator and DON stated their expectation that MDS assessments accurately reflect residents’ services and confirmed that failure to code hospice in the MDS results in an inaccurate reflection of the data.
Failure to Maintain Clean PTAC Unit Filters in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain Packaged Terminal Air Conditioner (PTAC) unit filters in a safe, clean condition in two resident rooms on the Sapphire Hallway. The facility’s written policy titled "Instructions" requires that air filters be removed and inspected for cleanliness, washed or replaced if dirty, and at a minimum replaced or thoroughly cleaned every three months. During multiple observations in one room on 3/22/2026, 3/24/2026, and 3/25/2026, the PTAC unit filter was noted to have visible grey, fuzzy debris accumulation, with no change in condition across all three observations. Similar repeated observations on those same dates in another room showed the PTAC unit filter also contained visible grey, fuzzy debris accumulation that remained unchanged. In an interview, the Maintenance Director stated he is responsible for cleaning and checking the PTAC filters monthly, including conducting monthly checks and random inspections in areas where construction is occurring, and confirmed that the maintenance department is responsible for ensuring filters are clean and functioning properly. He also stated that expectations include spot checks of PTAC units. However, during an observation of one of the affected rooms in his presence, dust accumulation was again observed on the PTAC unit filter, and he did not dispute the finding. In a separate interview, the Administrator stated that the maintenance department is responsible for cleaning PTAC filters, which are supposed to be cleaned monthly, and that her expectation is for preventative maintenance to be completed monthly and as needed, noting that a potential negative outcome is the impact on residents’ health and well-being.
Neglect of Incontinent Care and Delayed Wound Reporting Leading to Thigh Wound
Penalty
Summary
The deficiency involves the facility’s failure to prevent neglect and to assess and provide timely wound and incontinent care to a cognitively intact resident with known skin integrity risks. The resident, who had diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema, was care planned as being at risk for pressure ulcer development and skin integrity issues, with interventions directing staff to observe, document, and report any changes in skin status. On a night shift, the resident reported being left on a bedpan for approximately an hour and a half. When the CNA on that shift (CNA BB) assisted with post-toileting care, the resident told her she did not feel adequately cleaned; CNA BB did not recheck or further clean the resident and left the room. The next morning, the resident reported burning in the left upper thigh and informed another CNA (CNA EE) that she had not been cleaned well. During morning care, CNA EE found the pad under the resident soiled with feces and wet with urine and observed a blister on the resident’s left upper thigh, but did not report the new blister to the charge nurse or DON. A subsequent Skin Wound Note documented a new open area on the left posterior thigh with the resident reporting pain while sitting on the bedpan. Later, an NP wound care consult documented that the thigh wound had been present for approximately two weeks per nursing report and measured 3.5 cm x 4.0 cm x 0.2 cm, requiring sharp excisional debridement to remove necrotic tissue and decrease bacterial burden. On observation by the surveyor with the Wound Care Nurse, the left upper thigh area was open to air, shiny pink and granular, about the size of a half dollar. These findings demonstrate that the facility did not follow its abuse/neglect prevention policy and CNA job responsibilities to provide necessary care and to report changes in condition, resulting in neglect of incontinent care and delayed wound assessment and treatment for this resident.
Failure to Report Allegation of Neglect to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of neglect to the State Survey Agency (SSA) as required by its own abuse and neglect reporting policy. The facility’s policy, dated 1/2025, states that any complaint, allegation, observation, or suspicion of resident neglect must be immediately communicated to the Abuse Coordinator and promptly investigated and documented, and that all alleged violations involving mistreatment, abuse, or neglect will be thoroughly investigated under the direction of the Administrator in accordance with state and federal law. Despite this, the Administrator acknowledged that an allegation of neglect reported by a resident was not reported to the SSA. The resident involved was cognitively intact, with a BIMS score of 15, and had diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema. The resident reported that during a night shift she requested assistance for incontinent care after using a bedpan and experienced multiple delays before a CNA assisted her. She stated that when the CNA finally provided care, she did not feel adequately cleaned, and the CNA did not verify cleanliness before leaving. The next morning, another CNA found soiled linen with feces and a blister on the resident’s left upper thigh, which the resident reported as burning. A subsequent skin/wound note documented a new open area on the left posterior thigh. The resident texted the Administrator describing that a CNA had left feces on her and that she had developed a painful blister. The Administrator confirmed receiving this text but did not report the allegation of neglect to the SSA, despite being aware it should have been reported.
Failure to Update and Implement Care Plan for Newly Developed Pressure Ulcer
Penalty
Summary
Surveyors identified a failure to implement and update the care plan for a newly developed pressure ulcer for one resident. The facility’s policy "RAI Care Planning Management" requires a comprehensive, accurate assessment and real-time modification of the care plan when changes occur. The resident was admitted with diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema. A recent MDS quarterly assessment showed the resident was cognitively intact (BIMS 15), at risk for pressure ulcer development, and had no unhealed pressure ulcers at that time. The existing care plan, dated 6/6/2024, identified potential for pressure ulcer development and skin integrity issues related to immobility and lymphedema, with interventions to observe, document, and report changes in skin status, including wound size, stage, and signs of infection. Subsequently, a NP wound report documented a new open wound on the resident’s thigh that had been present for approximately two weeks, with specific measurements recorded. During observation and interview, the Wound Care Nurse and the resident confirmed the wound was on the left upper thigh, which differed from the NP report that referenced the right thigh. The MDS Coordinator reported she previously received weekly wound sheets from the Wound Care Nurse but had not received one in about a month, and that the DON was now responsible for emailing the weekly wound report. She verified that the last wound report she received did not include this resident and stated that new wounds should be discussed in the morning management meeting and the care plan updated in real time. The MDS Coordinator confirmed she only recently became aware of the upper left thigh wound and that the resident’s care plan had not been updated to reflect this new wound, resulting in a failure to implement care plan interventions for the newly developed pressure ulcer.
Failure to Complete Required GCHEXS Fingerprint Check for CNA
Penalty
Summary
The facility failed to ensure that a Georgia Criminal History Check System (GCHEXS) fingerprint check was conducted for one CNA among ten employee files reviewed, despite a census of eighty residents and a written policy requiring criminal background checks for all employment candidates. The policy titled "Freedom of Abuse Abuse Prevention Fast Alert" dated 1/2025 states that, as part of pre-employment screening, all candidates must authorize a criminal background check for conviction of crimes. During record review with the Human Resources Manager (HRM), there was no documentation of a fingerprint records check for CNA BB, and the HRM confirmed that this CNA did not have a GCHEXS fingerprint check conducted. The HRM also stated that she is responsible for background checks, fingerprint checks, reference checks, and maintaining employee files. This failure to complete the required fingerprint background check for CNA BB resulted in noncompliance cited under F-Tag 600. No resident-specific medical histories, conditions, or direct resident care events were described in the report related to this deficiency.
Failure to Maintain Safe and Clean Conditions in Multiple Resident Shower Rooms
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate environmental controls in multiple resident shower rooms. On the 4th floor, observation with the Unit Manager showed four razors on the floor, dirty gloves and a dirty comb on a shower bed, stained/dirty floors, an opened gallon bottle of complete bath soap, and a bottle of chemical resistant spray in the shower room. A razor and hair clippers were found in a black bag on the floor, and a shower cap and toothbrush were lying on the floor. The 4th floor Unit Manager stated that CNAs were supposed to clean up before showering residents and acknowledged that the items found should not be on the floor. The Environmental Senior Director reported that shower rooms were cleaned daily, with responsibilities including cleaning high-touch areas, sweeping and mopping floors, removing linen, and cleaning the area, and stated there had been no complaints about showers not being cleaned. On the 3rd floor, observation with the Unit Manager revealed an open bottle of skin and hair cleaner, an open bottle of conditioner, and an open bottle of skin ointment in the resident shower room. The 3rd floor Unit Manager stated that items in the shower room should be closed and that CNAs were to clean after each resident. On the 2nd floor, observation with the Unit Manager revealed two opened gallon containers of skin and hair cleaner and a strong urine odor in the shower room. The 2nd floor Unit Manager stated that the soap should have a top on it and that CNAs were responsible for cleaning after each resident. These observations and interviews showed that four of six resident shower rooms were not maintained free of hazards and were not cleaned as expected by facility staff, creating the potential for injury and spread of infection as stated in the report.
Improper Ice Scoop Handling and Storage Breaches Infection Control Protocol
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper handling and storage of ice scoops on two of four floors. On the 4th floor, observation of the ice scoop and scoop cover showed black specks near the end of the scoop used to put ice in cups, and the scoop cover was located on top of the ice machine. The 4th floor Unit Manager stated that kitchen staff cleaned the scoops once a week and acknowledged that the scoop should be clean. On the 3rd floor, observation of the ice chest/cooler used to serve residents revealed the ice scoop submerged in ice and water. The 3rd floor Unit Manager later confirmed that the ice scoop was not supposed to be left in the cooler. The Maintenance Director reported that maintenance staff were responsible for cleaning the ice machines, which were checked weekly and monthly, while nursing staff were responsible for cleaning the ice scoops and covers. The Staff Development Coordinator/Infection Control staff stated that all staff had been trained in infection control procedures, including hand hygiene and handling of the ice scoop and holder, and that staff had been educated that the ice scoop should be placed in the scoop holder after use and never left in the ice. Documentation in the maintenance logbook showed monthly checks and cleaning of all four ice machines, and the ice machine cleaning log showed that the ice machines on the 2nd, 3rd, and 4th floors and in the kitchen had been cleaned on specific dates. Staff training records indicated that an in-service on handwashing and ice scoop protocol had been provided for all staff.
Neglect Related to Inadequate Supervision and Unsafe Side Rail Use Leading to Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect related to inadequate supervision and oversight of side rail use, resulting in entrapment. Facility policies on Abuse, Neglect and Exploitation required protections to prevent neglect, defined as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy on Proper Use of Bed Rails required a person-centered approach, attempts at alternatives before bed rail use, and ensuring correct installation, use, and maintenance of bed rails, including attention to entrapment risk. For this resident, the Medicare 5-day MDS indicated moderate cognitive impairment (BIMS score of 8), total dependence on staff for all ADLs, and documented that bed rails were not used, while an admission assessment documented side rails were placed to assist with movement in bed. Facility records showed no evidence that safe rail spacing and regular inspection of side rails and beds had been completed. The resident had multiple serious medical diagnoses, including acute and subacute infective endocarditis, end stage renal disease, hemiplegia and hemiparesis following cerebral infarction, bacteremia, and cervical disc degeneration, and was dependent on staff for all ADLs. Nursing staff last observed the resident at 12:46 am when a sponge bath was provided; there was no documented monitoring or ADL assistance between 12:46 am and 4:30 am. The assigned CNA reported coming on duty at 11:00 pm, seeing the resident up with the bed in a low position, placing the call light in the resident’s hands, and not seeing or checking the resident again until approximately 4:30–5:00 am, stating that the resident did not press the call light during that time. Around 5:00 am, the CNA requested help from the RN, reporting that the resident needed assistance. The RN found the resident with the lower part of his body hanging off the bed and the upper body still on the bed, with his elbow wedged into the half side rail, requiring three staff to reposition him back into bed. The RN stated the resident, who was quadriplegic, was no longer as alert as when put to bed, did not respond to sternal rubs, had open but unfocused eyes, and was not verbally interactive. The CNA described finding the resident on his knees, all the way out of bed, with one hand tangled in the side rail, and noted that he was moaning but not talking after being returned to bed. Progress notes documented that EMS was called for evaluation and treatment due to the resident’s condition, and hospital ER records indicated he arrived with altered mental status and respiratory failure, agonal respirations, and a GCS of 3. The facility’s Maintenance Director stated bedrails had been checked the prior year but could not provide proof, and requested documentation of safe rail spacing and regular inspection was not provided.
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