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Health Inspection Summary
Bainbridge Island Health & Rehab Center
835 Madison Avenue North
Bainbridge Island, WA 98110
(206) 842-4765

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Deficiency Category
Inspection Date:
9/13/24
Complaint Reporting Period:
3/1/24 - 2/28/25
Inspection Date:
9/29/23
Complaint Reporting Period:
3/1/23 - 2/29/24
Inspection Date:
6/26/22
Complaint Reporting Period:
3/1/22 - 2/28/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies000
Quality of Life and Care Deficiencies226
Infection Control Deficiencies100
Resident Assessment and Care Planning Deficiencies044
Nursing and Physician Services Deficiencies000
Resident Rights Deficiencies004
Nutrition and Dietary Deficiencies111
Pharmacy Service Deficiencies021
Environmental Deficiencies000
Administration Deficiencies000

Detailed result for inspection on 9/13/24
Date of last standard health inspection:9/13/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25
No complaint inspections
Date(s) of infection control inspection(s) between 3/1/24 - 2/28/25
No infection control inspections
Total number of Health Deficiencies for this nursing home:4
Average number of Health Deficiencies in Washington:18.3
Average number of Health Deficiencies in the United States:9.6
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide safe and appropriate respiratory care for a resident when needed.

9/13/2410/18/24
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

9/13/2410/18/24
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

9/13/2410/18/24
2 - Minimal harm or potential for actual harm
Few
Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

9/13/2410/18/24
2 - Minimal harm or potential for actual harm
Some
Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 9/29/23
Date of last standard health inspection:9/29/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24
No complaint inspections
Date(s) of infection control inspection(s) between 3/1/23 - 2/29/24
No infection control inspections
Total number of Health Deficiencies for this nursing home:9
Average number of Health Deficiencies in Washington:15.1
Average number of Health Deficiencies in the United States:9.4
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

9/29/2311/14/23
2 - Minimal harm or potential for actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

9/29/2311/14/23
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

9/29/2311/14/23
2 - Minimal harm or potential for actual harm
Few

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

9/29/2311/14/23
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

9/29/2311/14/23
2 - Minimal harm or potential for actual harm
Few

Assess the resident when there is a significant change in condition

9/29/2311/14/23
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

9/29/2311/14/23
2 - Minimal harm or potential for actual harm
Some
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

9/29/2311/14/23
2 - Minimal harm or potential for actual harm
Few

Ensure each resident’s drug regimen must be free from unnecessary drugs.

9/29/2311/14/23
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 6/26/22
Date of last standard health inspection:6/26/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23
Date(s) of infection control inspection(s) between 3/1/22 - 2/28/23
No infection control inspections
Total number of Health Deficiencies for this nursing home:16
Average number of Health Deficiencies in Washington:18.4
Average number of Health Deficiencies in the United States:8.7
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide medically-related social services to help each resident achieve the highest possible quality of life.

6/26/227/28/22
2 - Minimal harm or potential for actual harm
Few

Provide or get specialized rehabilitative services as required for a resident.

6/26/227/28/22
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

6/26/227/28/22
2 - Minimal harm or potential for actual harm
Few

Provide safe and appropriate respiratory care for a resident when needed.

6/26/227/28/22
2 - Minimal harm or potential for actual harm
Some

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

1/3/231/4/23
3 - Actual harm
Few

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

6/26/227/28/22
2 - Minimal harm or potential for actual harm
Some
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

6/26/227/28/22
2 - Minimal harm or potential for actual harm
Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

6/26/227/28/22
2 - Minimal harm or potential for actual harm
Few

Ensure services provided by the nursing facility meet professional standards of quality.

6/26/227/28/22
2 - Minimal harm or potential for actual harm
Few

PASARR screening for Mental disorders or Intellectual Disabilities

6/26/227/28/22
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

6/26/227/28/22
2 - Minimal harm or potential for actual harm
Few

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

6/26/227/28/22
2 - Minimal harm or potential for actual harm
Few

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

6/26/227/28/22
1 - Potential for minimal harm
Some

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

6/26/227/28/22
2 - Minimal harm or potential for actual harm
Some
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

6/26/227/28/22
2 - Minimal harm or potential for actual harm
Some
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

6/26/227/28/22
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide or get specialized rehabilitative services as required for a resident.

6/26/227/28/22
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

1/3/231/4/23
3 - Actual harm
Few
Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.
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