Bainbridge Landing of Journey LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review and review of the facility's policies titled, Controlled Substance Administration and Accountability and Medication Administration, the facility failed to ensure the Controlled Substances Proof of Use form was signed after narcotic administration for one of 41 sampled residents (R) R8 during review of one of two medication carts. This deficient practice had the potential to cause incorrect narcotic counts, missed or overdose of narcotic medication for R8.Findings include: Review of the facility's policy titled, Controlled Substance Medication Accountability reviewed 02/14/2024 documented Policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. Policy Explanation and Compliance Guidelines:1. General Protocols:. f. All controlled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews and review of the facility's policy titled, Medication Storage, the facility failed to place open dates on two vials of blood glucose strips in one of two carts (100 hall cart) reviewed. This deficient practice had the potential to cause inaccurate blood sugar readings for the residents.Findings include:Review of the facility's policy titled, Medication Storage revised 02/14/2024 documented Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations.Observation and interview on 03/31/2026 at 11:52 AM during review of the 100 Hall medication cart revealed two blood glucose vials were in the top right drawer of the medication cart had no open dates. Licensed Practical Nurse (LPN) DD was present during the review, and she confirmed there were two blood glucose vials with no open dates in the top right drawer of the medication cart. LPN DD stated there should be open dates on the blood glucose strips because after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review and review of the facility's policies titled, Hand Hygiene and Infection Prevention and Control Program, the facility failed to practice infection control protocol by staff not practicing proper glove use and hand hygiene between glove change during wound care for one of six sampled residents (R) R2 with wounds, and during Foley catheter care for one of five sampled R's with Foley catheter, R42. This deficient practice had the potential to cause infection to the residents.Findings include:Review of the facility's policy titled Hand Hygiene revised 02/01/2024 documented Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the policy titled, Safe and Homelike Environment Policy and Procedure, the facility failed to maintain a clean and safe environment by ensuring that air filters in resident rooms were free from excessive dust in two of 37 sampled rooms (rooms [ROOM NUMBERS]). This deficient practice had the potential to create an unsafe and unclean homelike environment for residents.Findings include:Review of the facility's policy titled Safe and Homelike Environment Policy and Procedure, revised on 02/01/2024, documented Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Definitions:.Sanitary includes, but is not limited to,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of policy and procedures, the facility failed to ensure that racks were rust free and clean, air vent was clean, walls were clean, the brush was a cleanable surface, and dishes were properly sanitized in one of one kitchen and food was properly labeled and dated in one of one kitchenette in accordance with professional standards. The deficient practice has the potential to affect all 64 residents that received food by mouth. Findings include: Review of the facility's policy titled, Food Brought by Family/Visitors F813, last reviewed on 10/24, revealed Item one indicated family members would inform nursing staff of their wishes to bring in food for a resident. Item six indicated the foods would be labeled and dated. Review of the facility's policy titled, Sanitation F812, revised 10/22, revealed item two indicated utensils, counters and equipment shall be maintained in good repair (rusted shelves in walk-in, paint brush utensil used for putting butter on rolls and cooking oil on cookie sheets. Item eight indicated that sanitizing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure that it maintained a safe, comfortable, homelike interior on two of four areas/zones (100-hall and 300-hall) and one of one resident (Resident (R) 60) reviewed for environment. The deficient practice has the potential to affect the homelike environment for eight residents in four bedrooms. Findings include: Observation of bedroom [ROOM NUMBER], the bathroom shared with bedroom [ROOM NUMBER] on 04/07/25 at 3:00 PM revealed the sink to the bathroom was loosely fitted to the wall and leaning forward severely to the point water was not draining from the sink. In addition, a hole was noted behind the wall measuring four inches by four inches. The bathroom door inside bedroom [ROOM NUMBER] at the door handle was discolored and dirty for a 12-inch area. During an interview with the Administrator and Maintenance Director on 04/10/25 at 10:05 AM, both verified the conditions noted. Observation of bedroom [ROOM NUMBER], the bathroom shared with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility failed to equip handrails on each side of the corridor in four examples in two of four corridors reviewed for handrails. The deficient practice has the potential to affect 25 total residents' safety. Findings include: Observation on 04/08/25 at 4:10 PM revealed the corridor in the front of the building wall at the dining room measured 21 feet lacking a handrail between the two entrance doors to the large dining room. Observation on 04/08/25 at 4:10 PM revealed the corridor in the front section of the building wall at the public restroom area measuring eight feet, lacking a handrail. Observation on 04/08/25 at 4:15 PM revealed the corridor across from the main nursing station leading to the 300 unit measuring 13 feet, lacking a handrail. Observation on 04/08/25 at 4:15 PM revealed the corridor across from the nursing station leading to the 100 unit measuring eight feet, lacking a handrail. The interview with the Administrator on 04/10/25 at 10:05 AM verified the lack of handrails in the noted areas and indicated no one has ever…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, and resident and staff interviews, the facility failed to ensure the right to receive services with reasonable accommodation of needs and preferences for one of 22 sampled residents (Resident (R) 60) reviewed for accommodation of needs. This failure had the potential to affect the residents through increased isolation leading to depression. Findings include: Review of the Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed diagnoses of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease unspecified, type two diabetes mellitus, mild intermittent asthma, heart failure unspecified, ataxic gait, muscle weakness, hypertensive heart, chronic kidney disease, left side weakness, and depression Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date of 05/23/24 indicated R60 used his wheelchair to mobilize himself. His annual activity assessment indicated he preferred outings, television, movies, shopping, music, resident council, radio, and religion. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review, the facility failed to ensure the comprehensive significant change assessment was completed within 14 days and reflected to include a pressure ulcer and significant weight loss for one of 22 sample residents (Resident (R) 62) reviewed for comprehensive assessments. This failure had the potential to lead to a lack of adequate care planning to heal R62's pressure ulcer and prevent further breakdown and the potential to lead to a lack of timely medical intervention, appropriate nutritional support, and compromised health outcomes. Findings include: Review of the facility's policy titled, Comprehensive Assessment with a revised date of 08/22, revealed under Policy .A comprehensive assessment will be completed with defined significant change. Under Guidelines item 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews . Item c. When there has been a significant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview, and facility policy review, the facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one of 22 sample residents (Resident (R) 21) reviewed for MDS. This failure had the potential to contribute to inaccurate assessment and care planning and for (R) 21 to not receive needed care and services. Findings include: Review of the facility's policy and procedure titled, Comprehensive Assessment, dated 03/25, revealed the following: Residents will receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline. Review of R21's admission Record of the electronic medical record (EMR) located under the Admission tab, revealed an initial admission date of 05/02/18 with a diagnosis of Alzheimer's disease. Review of R21's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/22/25 and located in the EMR under the MDS tab, revealed R21 had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and facility policy review, the facility failed to ensure catheter drainage bags were maintained inside a privacy storage bag and were not in direct contact with the floor for two of five residents (Resident (R) 53, and R61) reviewed for catheters out of 22 sample residents. This deficient practice created a risk for cross-contamination and increased the potential for urinary tract infections compromising the health and safety of residents. Findings include: Review of the facility's policy titled, Policy- Infection Prevention and Control Program, dated January 2024, revealed, under Policy: 1. The Infection Control Committee shall oversee the internal community system for the preventing, identifying, reporting investigation, and controlling of infections and communicable diseases . Review of the facility's policy titled, Policy -Indwelling Urinary Catheters, dated June 2022, revealed under Infection Control: .2. b. Be sure the catheter tubing and drainage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the facility policy titled, Roommate Change, Roommate Notification, Choice of Roommate the facility failed to notify two of three residents (R) (R3 and R7) and/or responsible party of a room change prior to the room change and document the changes. Findings include, Review of the facility policy titled, Roommate Change, Roommate Notification, Choice of Roommate dated 4/2024. Under Policy Statement: The resident will receive a written notice, including the reason for the change before their room or roommate is changed. Under Policy Interpretation and Implementation number 2. Prior to changing a room or roommate assignment all parties involved will receive appropriate social services, to explain the move, provide an opportunity to see the new location, meet the new roommate (as applicable) and ask questions about the move. 1. Review of the medical records revealed R3 was admitted to the facility with the following diagnoses that include but not limited to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.