Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bainbridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Memorial Manor Nursing Home | 2.3 mi | ★★★★★ | 0 | 0 |
| Pinewood Health And Rehabilitation | 15.9 mi | ★★★★★ | 8 | 7 |
| Seminole Manor Nursing Home | 20.1 mi | ★★★★★ | 6 | 0 |
| Miller Nursing Home | 21 mi | ★★★★★ | 2 | 0 |
| Riverchase Health And Rehabilitation Center | 22.9 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.