Federal inspection record · CMS data as of October 1, 2026
Bainbridge Island Health & Rehab Center
835 Madison Avenue North, Bainbridge Island, WA · (206) 842-4765
- CMS high-performer trophy
- Certified beds
- 58
- Residents per day
- 44
- Ownership
- For-Profit
- Chain
- The Ensign Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- December 1, 1988
1
How this home got 5 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Washington.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★5 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Washington homes
Bainbridge Island Health & Rehab Center carries 36 inspection points. That is fewer than 88% of Washington's 192 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Washington: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–31 pts
- 4★ 31–69 pts
- 3★ 69–100 pts
- 2★ 100–167 pts
- 1★ over 167 pts
Bars show every rated home in Washington by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
22 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Resident Assessment and Care Planning6E
- E
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Assess the resident when there is a significant change in condition
- D
Ensure each resident receives an accurate assessment.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Quality of Life and Care6D
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide activities to meet all resident's needs.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Nutrition and Dietary3E
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Pharmacy Service3D
- D
Ensure that residents are free from significant medication errors.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
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.
Infection Control2E
- E
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
Freedom from Abuse, Neglect, and Exploitation2D
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspection history
2025-11-17
8 health deficiencies · 9 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2024-09-13
5 health deficiencies · 7 fire-safety deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2023-09-29
9 health deficiencies · 5 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 46 min of nursing staff time a day, 1 h 8 min of it from a registered nurse.
This home
3 h 46 min
Washington average
4 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 19% of nursing staff and 17% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.4 pts worse | 95.8% | 96.2% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine5.7 pts better | 100.0% | 94.3% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.9 pts better | 1.7% | 2.6% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms23.5 pts worse | 41.4% | 17.9% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.7 pts worse | 7.3% | 5.6% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication2.2 pts worse | 14.7% | 12.5% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication14.9 pts worse | 29.9% | 15.0% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened9.9 pts better | 5.7% | 15.6% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased7.8 pts better | 6.0% | 13.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.8 pts better | 0.0% | 0.8% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1.7 pts better | 0.0% | 1.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence9.4 pts better | 12.2% | 21.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2.3 pts better | 2.1% | 4.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine5.7 pts better | 94.4% | 88.7% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit4.6 pts better | 8.4% | 13.0% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medicationAbout the same | 1.3% | 1.3% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine0.3 pts better | 84.7% | 84.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission9 pts better | 10.7% | 19.7% | 23.4% |
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Who owns and runs it
13 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Bainbridge Health Holdings LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Burnam, Soon | Corporate Officer · Individual | 0% | 353 facilities |
| De Oro, Thomas | Managing Control - Governing Body · Individual | 0% | 2 facilities |
| De Oro, Thomas | Operational/Managerial Control · Individual | 0% | 2 facilities |
| De Oro, Thomas | Adp Of The SNF · Individual | 0% | 2 facilities |
| Farnsworth, Stephen | Corporate Officer · Individual | 0% | 38 facilities |
| Keetch, Chad | Corporate Officer · Individual | 0% | 301 facilities |
| Kretchmar, Joshua | Managing Control - Governing Body · Individual | 0% | 4 facilities |
| Kretchmar, Joshua | Operational/Managerial Control · Individual | 0% | 4 facilities |
| Kretchmar, Joshua | Adp Of The SNF · Individual | 0% | 4 facilities |
| Port, Barry | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 203 facilities |
| Standard Bearer Healthcare Op LP | Adp Of The SNF · Organization | 0% | 21 facilities |
| The Ensign Group Inc | Adp Of The SNF · Organization | 0% | 135 facilities |
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Fire safety
21 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Emergency Preparedness6F
- F
Conduct testing and exercise requirements.
- F
Address subsistence needs for staff and patients.
- F
Provide a means of sharing information on occupancy/needs.
- F
Conduct testing and exercise requirements.
- F
Address subsistence needs for staff and patients.
- F
Conduct testing and exercise requirements.
Smoke5F
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
Miscellaneous3F
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F
Have simulated fire drills held at unexpected times.
- E
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems3F
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Ensure proper usage of power strips and extension cords.
Services2F
- D
Have properly installed electrical wiring and gas equipment.
- F
Have properly installed electrical wiring and gas equipment.
Egress1F
- F
Install proper backup exit lighting.
Construction1D
- D
Meet other general requirements.
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