Bainbridge Health And Rehab

F-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 water for equipment and pots and pans shall be at 150-200 PPM [parts per million]. The policy does not address how long items that were washed shall be submerged in the sanitizing solution. Item 17 indicated that kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent the accumulation of grime (wall vent and wall above pots and pans). No such cleaning schedule was available at the time of the survey.

Observation on 04/07/25 at 10:00 AM revealed two metal four rack shelves in the walk-in refrigerator in the main kitchen each measuring five feet high by four feet wide. All four shelves on each rack were severely rusted including flaking rust. The shelves were holding food items such as fruit and containers with food and vegetables. In addition, on 04/07/25 at 10:05 AM, a small two rack set of shelves were under the coffee machine table holding coffee supplies such as coffee, coffee containers, and coffee filters. The racks were also severely rusted with flaking rust. During an interview on 04/07/25 at 10:05 AM the Dietary Manager (DM) verified the condition of the shelves in both areas and stated she was considering moving the shelves and replacing them with clean plastic shelves and racks.

Observation on 04/09/25 at 9:35 AM revealed a four-foot high by three-foot-wide return air vent on the wall near the prep sink to be full of dirt and grease. Interview with the DM at the time of the observation stated

she put in a request for maintenance to clean. The condition of this vent was verified by the Registered Dietician (RD) on 04/09/25 at 10:30 AM.

Observation of the light switch on the wall near the exit door on 04/09/25 at 9:40 AM revealed brown dirt/discoloration on the wall 12 inches below and above the light switch. Interview with the DM at the time of

the observation verified the condition of the light switch. The condition of this wall was verified by the RD on 04/09/25 at 10:30 AM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 115324 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115324 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bainbridge Health and Rehab 1155 West College Street Bainbridge, GA 39819

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Observation of the outside exit door on 04/09/25 at 9:40 AM revealed the door had a one-inch gap at the base of the door allowing for the passage of bugs and possible rodents. The wooden screen door at this exit Level of Harm - Minimal harm or door was open during meal service. Interview with the DM at the time of the observation verified the potential for actual harm condition of the base of the door and the gap. The condition of this door was verified with the RD on 04/09/25 at 10:30 AM. Residents Affected - Many

Observation on 04/09/25 at 9:40 AM revealed the wall at the ceiling above the hanging pots and pans rack revealed large amounts of dust and dirt hanging from the wall two feet down from the ceiling extending five feet in length. Interview with the DM at the time of the observation verified the condition of the wall. The condition of this wall was verified by the RD on 04/09/25 at 10:30 AM.

Observation on 04/09/25 at 9:50 AM revealed the DM was spreading vegetable oil on three large cookie sheets with a paint brush in the main kitchen. The brush had severely curled, charred bristles with a wooden handle burned in two locations. She later placed dozens of chicken breasts on each cookie sheet for which vegetable oil was applied with the paint brush. Interview with the DM at the time of the observation indicated

she has been using paint brushes for years for this application and it was cleaned in the dishwasher before each use. The DM stated the same paint brush was also used for several purposes. On 04/09/25 at 1:20 PM, Dietary Aide (DA) 2 was observed spreading butter on a large cookie sheet full of dinner rolls. She dipped

the paint brush noted above in warm butter and spread the butter across all of the dinner rolls repeatedly until all were coated on the top with butter.

Observation on 04/09/25 at 9:55 AM revealed DA1 washing pots and pans in the three-compartment sink in

the main kitchen. The sink was tested for sanitizer added to the water. The test showed 700 PPM (parts per million). DA1 stated that it was correct. The sanitation solution sink had six inches of water thus leaving a large prep bowl and another stainless-steel container eight inches wide by 18 inches long laying on top of the water and not submerged in the sanitizing solution. Interview on 04/09/25 at 10:15 AM with the DM and the RD verified the items were not properly submerged and would not sanitize the containers as intended.

Further interview with the DM on 04/09/25 at 10:15 AM indicated the seal on the drain of the sink leaked causing the water to drain early leaving the pots and pan above the water line. She stated she put in a maintenance request two weeks ago. The interview with the Maintenance Director (MD) at 10:20 AM indicated he had a replacement seal for the sink and would install it immediately. He also indicated he had not received a maintenance request in Tel's (system to log and track maintenance issues) to repair the sink drain. The sink was repaired at 10:45 AM.

Observation of the kitchenette near the main nursing station on 04/09/25 at 10:05 AM revealed a refrigerator freezer with chocolate ice cream container open at the top with whip cream on the top of the ice cream without a label or date, completely frozen rock solid. In the refrigerator, a Tupperware container six inches wide by 10 inches long labeled with the name of a current resident to be lacking a label of contents and date.

The contents appeared to be ground beef in marinara sauce with macaroni. Interview with the Director of Nursing (DON) at the time of the observation verified the contents noted above. She indicated dietary staff were responsible for the condition of the refrigerator and she thought the family brought the food in yesterday (04/08/25) for the resident and placed it into the refrigerator without telling staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 115324 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115324 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bainbridge Health and Rehab 1155 West College Street Bainbridge, GA 39819

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 07246 potential for actual harm Based on observations, record review, staff interviews, and facility policy review, the facility failed to ensure Residents Affected - Few 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 Resident 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 bag are kept off the floor .

1. Review of Resident R53's Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility

on [DATE REDACTED] with diagnoses including cellulitis of the groin, and acute and chronic respiratory failure with hypoxia. Resident R53 was admitted to hospice care on 04/04/25.

Review of Resident R53's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/21/24 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated intact cognition. Resident R53 used an indwelling/suprapubic urinary catheter.

Review of Resident R53's Care Plan, dated 12/19/24 and located in the Care Plan tab of the EMR, revealed Resident R53 was at risk for UTI (Urinary Tract Infection) for obstructive uropathy, and history of UTI. Resident R53 used an indwelling urinary catheter and had a goal of signs and symptoms of urinary tract infection will be minimized daily.

During an observation and interview on 04/08/25 at 11:49 AM, Resident R53 was observed lying in bed. The indwelling catheter urinary container bag was not covered in a privacy storage bag and was lying on the floor

in direct contact with the floor. Licensed Practical Nurse (LPN) 1 revealed that foley catheter bags usually had a liner cover on them, and confirmed indwelling foley container drainage bags should not be lying on the floor to prevent the spread of infection.

2. Review of Resident R61's Profile tab of the EMR revealed he was admitted to the facility on [DATE REDACTED] with diagnoses including polyneuropathy, diabetes mellitus, and urethral stricture.

Review of Resident R61's quarterly MDS with an ARD of 02/01/25, located in the MDS tab of the EMR, revealed a BIMS score of eight out of 15 which indicated Resident R61 was moderately cognitively impaired and indicated Resident R61 used an indwelling/suprapubic urinary catheter.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 115324 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115324 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bainbridge Health and Rehab 1155 West College Street Bainbridge, GA 39819

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of Resident R61's Care Plan, revised on 07/29/24 and located in the Care Plan tab of the EMR, revealed Resident R61 was on EBP (Enhanced Barrier Infection Precautions) due to suprapubic catheter. Resident R61 used an indwelling Level of Harm - Minimal harm or suprapubic urinary catheter and had a goal of appropriate precautions would be taken. potential for actual harm

During an observation on 04/07/25 at 10:49 AM, Resident R61 was observed lying in bed. The indwelling suprapubic Residents Affected - Few urinary catheter container bag was not covered in a privacy storage bag.

During an observation and interview on 04/08/25 at 11:49 AM, Resident R61's indwelling suprapubic urinary catheter container bag was not covered in a privacy storage bag, and the bottom of urinary catheter container collection bag was directly touching the floor. LPN1 revealed that foley catheter bags usually had a liner cover on the container collection bag, and confirmed the indwelling foley container drainage bag should not have been lying on the floor to prevent the spread of infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 115324 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115324 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bainbridge Health and Rehab 1155 West College Street Bainbridge, GA 39819

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0924 Put firmly secured handrails on each side of hallways.

Level of Harm - Minimal harm or 07342 potential for actual harm Based on observations and staff interviews, the facility failed to equip handrails on each side of the corridor Residents Affected - Some 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 said anything about this in the past.

Interview with the Maintenance Director on 04/10/25 at 10:06 AM verified the corridors noted were not equipped with handrails.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 115324

F-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