Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Island Health & Rehab Center during CMS and state inspections, most recent first.
A resident with dementia and depression was physically assaulted by another resident with TBI, dementia, and a mental health disorder after a hallway confrontation. The assaulted resident had a history of verbal altercations and the other resident had poor impulse control and a history of striking out when agitated. A CNA witnessed the other resident hit the resident on the side of the head, and the other resident admitted to tapping the resident to stop the yelling and send a message not to threaten them.
Psychotropic medication monitoring and behavior plans were not accurately individualized for two residents. One resident with anxiety and dementia had Buspirone and escitalopram for perseveration on medical concerns, but the MARs had no documentation of the ordered non-pharmacological interventions. Another resident with anxiety and bipolar disorder had escitalopram, but the MAR listed tearfulness as the target behavior even though the care plan, IDT review, and family input identified verbalization of anxiety; the behavioral interventions on the MAR also did not match the care plan.
Failure to follow MD orders and accurately document care for two residents. One resident at risk for pressure injuries was ordered a low air loss mattress with bolster cover, but observations showed a foam mattress with bolsters instead, while nurses signed the TAR as if the ordered mattress had been checked and functioning. Another resident with heart disease had an order for PRN Midodrine for hypotension, but the MAR showed low SBP readings with no documentation that the medication was given, and the DON confirmed the doses were not administered as ordered.
Failure to Provide Meaningful Activities for Cognitively Impaired Residents: Two residents with cognitive impairment did not receive activity programming aligned with their assessed needs and preferences. One resident with severe dementia was repeatedly observed sitting in a hallway near the nurse’s station with no activity materials, while the activity plan called for 1:1, sensory, and low-stimulation programming. Another resident’s preferred activities were not identified on the care plan, the activity admission evaluation remained incomplete, and the resident was observed in a noisy hallway receiving a paper activity without meaningful follow-up or direct engagement.
Pureed Meal Preparation Did Not Follow Recipe: A cook was observed preparing pureed sausage by using unmeasured water and unmeasured thickener, then adjusting the mixture by sight and hand mixing until it appeared acceptable. The cook stated a recipe existed but relied on experience instead of following it. The recipe reviewed specified exact amounts of sausage, water or broth, and thickener to maintain recipe integrity and serving amount for residents on pureed diets.
A facility failed to maintain a sanitary kitchen environment, leading to a risk of cross-contamination. A cook engaged in unsanitary practices, such as handling food with contaminated gloves and not cleaning a thermometer between uses. The Dietary Supervisor and facility administrators acknowledged these actions were against food safety protocols.
A resident with severe cognitive impairment did not receive appropriate bowel management care as per physician orders, leading to extended periods without bowel movements. The facility failed to administer prescribed medications and document bowel management, as confirmed by staff interviews and records.
A facility failed to maintain and properly document the change of oxygen tubing for a resident with moderate cognitive impairment. The resident's physician ordered the tubing to be changed weekly, but discrepancies were found in the dating of the tubing, and the Treatment Administration Record did not align with observations. The DON confirmed the tubing should have been changed as ordered and that staff should not sign off on incomplete tasks.
A registered nurse failed to follow proper transmission-based precautions by wearing an N95 mask over a surgical mask and not changing the surgical mask between rooms. Interviews with an LPN and the DON confirmed the correct PPE procedure, which was not followed, leading to a deficiency in infection control practices.
Resident struck by another resident after hallway confrontation
Penalty
Summary
The facility failed to ensure residents were free from physical abuse by another resident for 1 of 3 residents reviewed. The facility policy stated residents had the right to be free from abuse, including willful infliction of injury or intimidation resulting in physical harm, pain, or mental anguish. Resident 1 was admitted with diagnoses of dementia and depression, and the admission MDS showed moderate cognitive impairment and verbal behavioral symptoms directed toward others. Resident 1’s care plan identified a history of verbally abusive behavior, yelling, and risk for harm due to aggressive behavior, and documented verbal altercations with other residents on multiple occasions. Resident 2 was admitted with diagnoses including traumatic brain injury, dementia, and a mental health disorder, and the annual MDS showed moderate cognitive impairment. Resident 2’s care plan identified poor impulse control, psychosis, and a tendency to strike out at male residents when agitated. A facility incident report showed Resident 1 and Resident 2 encountered each other in the hallway, Resident 1 yelled, and Resident 2 backhanded Resident 1, knocking off Resident 1’s hat and glasses and using profanity. A CNA witnessed Resident 2 strike Resident 1 on the side of the head, and Resident 2 stated they hit Resident 1 to stop the yelling and wanted Resident 1 to know not to threaten them. The DON stated Resident 1 had been verbally explosive and volatile, and Resident 2 had poor tolerance for certain people and had not been expected to react physically.
Psychotropic Medication Monitoring and Behavior Plans Were Not Individualized
Penalty
Summary
The facility failed to accurately identify and monitor target behaviors for psychotropic medications and failed to individualize behavior interventions for two residents reviewed for unnecessary medications. The deficiency involved Resident 32, who was admitted with anxiety disorder and dementia and had moderate cognitive impairment on MDS assessment, and Resident 7, who was admitted with diagnoses of anxiety disorder and bipolar disorder and was cognitively intact on admission assessment. For Resident 32, staff documentation showed ongoing anxiety-related behaviors, including perseveration on medical conditions, worry, and difficulty redirecting attention. The resident’s care plans and IDT reviews identified Buspirone and escitalopram for anxiety, with non-pharmacological interventions such as redirection, reassurance, quiet environment, snacks, fluids, and one-on-one support. However, the MARs for August and September showed no documentation that these interventions were actually provided, and the behavioral target remained broadly described as perseverating on medical conditions. The IDT review also noted the resident had 35+ episodes on day shift in August, and the psychiatric follow-up note documented increased anxiety symptoms and an increase in Buspar, but the behavioral interventions section had no documentation. For Resident 7, the admission MDS showed no behaviors and minimal depression, yet escitalopram was ordered for depression. The Behavior/Psychoactive Medication IDT Review documented that the resident’s son reported verbalization of anxiety as the best indicator of anxiety, and the target behavior was changed from social isolation to verbalization of anxiety. Despite this, the September MAR listed the target behavior as tearfulness, which did not match the care plan, the IDT review, or the son’s report. The MAR also listed behavioral interventions that did not match those identified in the care plan, and the DON confirmed that staff were monitoring for tearfulness even though that was not the identified target behavior.
Failure to Follow Physician Orders and Document Completed Care
Penalty
Summary
The facility failed to ensure services met professional standards of practice for two residents. For one resident, who was cognitively intact and assessed as at risk for pressure injuries, the electronic record included an order for a low air loss mattress with bolster cover and directions for nursing staff to check the mattress every shift for placement and function. The care plan also documented use of a low air loss mattress and directed licensed nurses to ensure proper functioning every shift. However, observations on multiple occasions showed the resident did not have a low air loss mattress in place, and the treatment administration record showed nurses signed that they validated the placement and function of the mattress on 12 of 13 shifts during the survey period. The DON confirmed the resident had a foam mattress with bolsters, not the ordered low air loss mattress, and that nurses had signed for a task they had not completed. For another resident admitted with heart disease, the physician ordered Midodrine every 12 hours as needed for hypotension if systolic blood pressure was less than 100. The medication administration record showed blood pressure readings of 86/57 and 89/60, but there was no documentation that Midodrine was administered on either occasion. The DON reviewed the record and confirmed staff did not administer the medication as ordered on those dates.
Failure to Provide Meaningful Activities for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide activity programming designed for and to support cognitively impaired residents in their preferred activities for two residents reviewed for activities. The deficiency was identified during observation, interview, and record review and involved Resident 26 and Resident 53. The facility’s activities policy stated that residents would receive an ongoing program of activities designed to meet their interests and physical, mental, and psychosocial well-being, with meaningful activities provided throughout the day and evening based on each resident’s needs and preferences. Resident 26 was admitted with severe dementia and had an MDS showing severe cognitive impairment and a need for staff assistance with activities of daily living. The activity care plan identified a potential alteration in diversional activities and stated the resident would benefit from 1:1 activity visits, sensory stimulation programming, and small group settings. The plan also directed staff to encourage participation in all activities, especially small group activities, provide low-stimulation activities when available, assist outside for fresh air, and provide 1:1 programming with supplies, conversation, and comfort. Psychiatric follow-up notes stated staff were to encourage structured activities to support orientation and reduce agitation. During multiple observations, Resident 26 was seen sitting in the hallway in front of the nursing station, staring down the hallway, attempting to stand, and having no food, fluids, or activity materials available. Staff repeatedly redirected the resident to sit down. The activity director stated activities were provided based on assessment and care plans, but low-stimulation small group activities were not listed on the calendar, and 1:1 activities were provided when needed or when residents appeared bored. The resident’s activity task documentation from 09/01/2025 through 09/22/2025 showed only limited creative, mental, social, and religious activities, with no entertainment or 1:1 activity documented. Resident 53 was admitted with cognitive impairment and dependence on staff for most ADLs. The admission MDS identified activity preferences including listening to music, access to newspapers, books, and magazines, going outside for fresh air when weather was nice, and being around pets/animals as very important. The activity CAA identified risk for reduced activity participation due to cognition, depression, and anxiety, and the initial care plan directed staff to engage the resident in simple, structured activities that avoided overly demanding tasks. However, the resident’s preferred activities were not identified on the initial care plan, and the activity admission evaluation remained incomplete 11 days after admission. During observation, Resident 53 was seated in a wheelchair in the hallway in front of the nurse’s station in a noisy area with multiple staff and visitors moving around. Staff D passed out papers to residents in the area, including Resident 53, but did not directly interact with the resident afterward. The resident appeared not to understand the paper and remained holding it without further staff interaction. Activity documentation showed only limited participation in a word/card game, a reading activity, and passive television watching, with no social, religious, trips, or 1:1 activities documented during the reviewed period.
Pureed Meal Preparation Did Not Follow Recipe
Penalty
Summary
The facility failed to ensure food was prepared in a manner that conserved nutritive value and palatability for 3 of 3 residents who required pureed meals: Residents 53, 6, and 19. On 09/25/2025 at 6:44 AM, a cook was observed preparing pureed sausage links by pushing approximately 16 link sausages off a pan into a metal tin, dumping the tin into a food processor, pulsing it three times, transferring the contents to a pitcher, adding an unmeasured amount of hot water from a beverage machine, and blending the mixture again. The mixture was observed to be thin and soupy, and the cook then added thickener by tapping the container on the edge of the food processor and later on the edge of the container, delivering unmeasured amounts each time while mixing by hand. When asked about the preparation, the cook stated there was a recipe but said they had been a cook for so long that they could prepare the correct texture by looking at it. The pureed sausage recipe reviewed by surveyors directed staff to use 25 sausage links with 3 1/4 cups of water or broth and 2 tablespoons of thickener, and to adjust the recipe if single portion food items varied in size to maintain recipe integrity and serving amount. Later that morning, another staff member stated that cooks should follow the pureed recipes when preparing pureed food to ensure nutritive value, palatability, and appropriate texture were maintained.
Food Safety Deficiency Due to Unsanitary Practices
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, which compromised food safety and increased the risk of cross-contamination. During observations, a cook, identified as Staff H, repeatedly engaged in unsanitary practices. These included picking up a pen from the floor without cleaning it, using the same pen while wearing gloves, and then handling food items without changing gloves. Staff H also failed to clean a thermometer between temperature checks of different food items and frequently touched personal items such as glasses and a name tag without washing hands or changing gloves before resuming food handling. The Dietary Supervisor, Staff I, acknowledged that the actions observed were not in line with expected food safety practices, such as using clean gloves after interruptions and using utensils instead of hands for food handling. The facility administrators, Staff A and Staff C, confirmed that the observed practices were unacceptable and did not meet the guidelines for preventing cross-contamination and foodborne illness. The report highlights a significant deficiency in the facility's adherence to food safety protocols, as outlined in WAC 388-97-1100.
Failure to Follow Bowel Management Protocol
Penalty
Summary
The facility failed to provide necessary bowel management care for a resident, identified as Resident 27, who was severely cognitively impaired. The resident had specific physician orders for bowel management, including the administration of Miralax, bisacodyl, and Fleet enema, to be followed if there was no bowel movement after three days. However, the facility did not adhere to these orders on multiple occasions, resulting in extended periods without bowel movements. For instance, there were documented instances where the resident went five, nine, thirteen, and six days without a bowel movement, and the bowel protocol was not initiated as per the physician's orders. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing Services, revealed inconsistencies in the implementation of the bowel management protocol. Staff acknowledged that the bowel protocol should have been initiated after three days without a bowel movement, but this was not done for Resident 27. The Medication Administration Record and Treatment Administration Record showed lapses in administering the prescribed medications, and there was a lack of documentation regarding bowel management during the specified periods. This failure to follow the bowel management protocol placed the resident at risk for discomfort and diminished quality of life.
Failure to Properly Maintain and Document Oxygen Tubing Changes
Penalty
Summary
The facility failed to maintain, label, date, and properly store oxygen tubing and supplies for a resident requiring respiratory care. Resident 9, who was moderately cognitively impaired, had a physician's order for oxygen tubing to be changed every Sunday or as needed. Observations on two separate occasions showed discrepancies in the dating of the oxygen tubing. On one occasion, the tubing was dated 09/01/2024, and on another, it was dated 09/11/2024, despite the Treatment Administration Record indicating changes on 09/01/2024 and 09/08/2024. The Director of Nursing Services confirmed that the tubing should have been changed as per the order and acknowledged that staff should not sign off on tasks that have not been completed.
Improper PPE Use in COVID-Positive Room
Penalty
Summary
The facility failed to adhere to proper transmission-based precautions (TBP) when donning and doffing personal protective equipment (PPE) in a COVID-positive room. During a lunch meal service, a registered nurse, identified as Staff J, improperly donned PPE by wearing an N95 mask over an already worn surgical mask and gloves before entering a resident's room. After exiting the room, Staff J removed the N95 mask and gloves but continued to wear the same surgical mask into another room. Interviews with Staff D, a Licensed Practical Nurse/Resident Care Manager, and Staff B, the Director of Nursing Services, confirmed that the correct procedure for donning PPE in a COVID-positive room includes wearing a gown, N95 mask, goggles, and gloves, and that double masking is not acceptable. The observation of improper PPE use was acknowledged as unacceptable by the Director of Nursing Services.
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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 Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bremerton Trails Post Acute | 6.1 mi | ★★★★★ | 55 | 0 |
| Belmont Terrace | 6.1 mi | ★★★★★ | 22 | 0 |
| Avamere Rehabilitation At Park West | 6.8 mi | ★★★★★ | 1 | 0 |
| Washington Veteran Home-retsil | 7.2 mi | ★★★★★ | 19 | 0 |
| Queen Anne Healthcare | 8 mi | ★★★★★ | 18 | 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.