Bainbridge Island Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Bainbridge Island Health & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 3, 2023

  Based on interview and record review, the facility failed to implement care planned interventions to prevent a fall for 1 of 4 residents (Resident 1) reviewed for falls. This failure resulted in harm when Resident 1 rolled out of bed during care and sustained a leg fracture. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses to include stroke and right sided weakness. Review of the Minimum Data Set assessment, dated 11/30/2022, showed the resident required extensive assistance of two people with bed mobility. Resident 1's Activity of Daily Living care plan, dated 09/12/2021, showed Resident 1 required two staff persons to reposition and turn Resident 1 in bed. […]

• No harm, potential for more than minimal, patternF658Aug 20, 2026

  Based on interviews and record review, the facility failed to follow professional nursing standards for wound care and documentation for 2 of 3 residents (Resident 3 and 4) reviewed for wound care. This failure placed residents at risk of clinical complications, infection and inaccurate medical records.Findings included.RESIDENT 3Resident 3 was admitted on [DATE] after hospitalization for hip surgery.Review of Resident 3's physician orders, dated 08/05/2026, showed a wound care order to the left hip surgical incision every day.Review of Resident 3's Treatment Administration Record (TAR), dated 08/01/2026 through 08/31/2026, showed documentation the wound care was completed daily from 08/06/2026 through 08/11/2026.Review of the facility's investigation report, dated 08/11/2026 at 1700 (5:00… […]

• No harm, potential for more than minimal, patternF880Aug 20, 2026

  Based on observations, interviews and record review, facility staff failed to perform hand hygiene and maintain separation between clean and dirty tasks during wound care for 2 of 3 staff (Staff A and B) observed. This failure placed residents at risk of contagious disease, infection and clinical complications.Findings included.Review of the Center of Disease Control's webpage titled, Clinical Safety: Hand Hygiene for Healthcare Workers, dated 02/27/2024, showed healthcare personnel should perform hand hygiene and change gloves when moving from work on a soiled body site to a clean body site on the same patient.STAFF AOn 08/20/2026 at 10:33 AM, Staff A, Licensed Practical Nurse (LPN), was observed providing wound care on Resident 1's heel. […]

• No harm, potential for more than minimal, patternF812Sep 13, 2024

  Based on observation and interview, the facility failed to maintain a kitchen environment which allowed each resident to have nourishing, palatable and well-balanced meals without cross contamination for 1 of 1 kitchen reviewed for food safety. This failure put residents at risk for food-borne illness, unsanitary conditions, and a diminished quality of life. Findings included . <Food preparation observations> On 09/11/2024 at 11:53 AM, Staff H, Cook, dropped his writing pen on the floor, he picked it up with bare hands and did not clean the pen. Staff H then wrote on a clip board and put the pen back onto his shirt by clipping the pen onto his shirt collar. Staff H did not wash hands after using the pen. […]

• No harm, potential for more than minimal, patternF812Sep 29, 2023

  Based on observation, interview and record review, the facility failed to ensure food products were dated when opened, discarded when beyond the use by date, kitchen equipment was clean and sanitary, food holding temperatures were accurately obtained and recorded, and that the low temperature dishwasher washer met the minimum wash and rinse cycle temperatures and the required minimum chemical concentration of sanitizer for proper cleaning and sanitization of resident dishes and utensils. Failure to ensure food was held at appropriate temperatures prior to serving, that meals were served on clean and sanitized disheware, and that outdated food products were not served to residents placed residents at risk for unpalatable food and foodborne illness. […]