Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 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 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.
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 | — | 52 | 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 | — | 1 | 0 |
| Queen Anne Healthcare | 8 mi | — | 0 | 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 August 2026) and official state health department websites.