Bainbridge Island, WA
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
835 Madison Avenue North, Bainbridge Island, WA
(206) 842-4765
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
58
Certified beds
Average residents
41
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1988-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
1.32
Registered nurse staffing
LPN hours / resident day
0.35
Licensed practical nurse staffing
Aide hours / resident day
2.24
Nurse aide staffing
Weekend hours
3.08
Weekend nurse staffing
RN turnover
17%
Annual RN turnover
Total nurse turnover
36%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
96.0%
0.5 pts worse
|
93.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.7% |
93.8%
8.1 pts worse
|
95.5%
9.8 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
2.6%
0.1 pts worse
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 28.8% |
16.3%
12.5 pts worse
|
11.4%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.1% |
5.8%
3.7 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.5% |
12.1%
0.4 pts worse
|
19.6%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 20.0% |
15.9%
4.1 pts worse
|
16.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.3% |
20.0%
16.7 pts better
|
16.3%
13 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.4% |
15.8%
12.4 pts better
|
14.9%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.2%
1.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
1.7%
0.1 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.4% |
23.5%
14.1 pts better
|
19.8%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.7%
2.6 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.6% |
87.7%
3.9 pts better
|
81.7%
9.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.6% |
13.2%
9.6 pts better
|
12.0%
8.4 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.4%
1.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.4% |
82.0%
0.4 pts better
|
79.7%
2.7 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.2% |
19.9%
1.3 pts worse
|
23.9%
2.7 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-11-03
Fire Safety
Install proper backup exit lighting.
Corrected 2025-11-03
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-11-03
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-11-03
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-11-03
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-11-03
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-11-03
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-11-03
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-11-03
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-10-01
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-10-01
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-01
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-09-17
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-01
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-01
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-01
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-10-31
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-31
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-31
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-31
Fire Safety
Meet other general requirements.
Corrected 2023-10-31
Inspection history
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-12-26
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-26
Health
Provide activities to meet all resident's needs.
Corrected 2025-12-26
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-12-26
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-07
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-18
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-18
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-18
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-18
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-14
Health
Assess the resident when there is a significant change in condition
Corrected 2023-11-14
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-14
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-11-14
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-11-14
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-14
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-14
Health
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.
Corrected 2023-11-14
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-11-14
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Nearby options
Bremerton, WA
1-star overall rating with 1-star inspections with $65,908 in total fines with 29 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Bremerton, WA
2-star overall rating with 1-star inspections with $9,750 in total fines with 39 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Seattle, WA
2-star overall rating with 2-star inspections with $29,820 in total fines with 20 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
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