Bainbridge Island Health & Rehab Center
835 Madison Avenue North, Bainbridge Island, WA 98110
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Follow this homeBainbridge Island Health & Rehab Center is a nursing home in Bainbridge Island, Washington. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating5 of 5
- Last standard health inspectionNovember 17, 2025 (11 months ago)
- Health citations since September 29, 202322 (Washington average 50)
- Fines in the past three yearsNone listed by CMS
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS health inspection star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
Health inspection on August 20, 2026
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0658. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on September 25, 2026.
CMS has cited this home for F0658 2 times since 2025.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 25, 2026.
CMS has cited this home for F0880 2 times since 2024.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
Health inspection on July 1, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on August 1, 2026.
CMS has cited this home for F0684 2 times since 2024.
Health inspection on May 6, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on June 1, 2026.
Health inspection on November 17, 2025
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation F0605. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on December 26, 2025.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on December 26, 2025.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on December 26, 2025.
Citation F0804. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on December 26, 2025.
Fire safety inspection on November 17, 2025
9 citationsCMS lists this as a standard inspection.
Show the 9 citations
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on November 3, 2025.
CMS has cited this home for E0039 3 times since 2023.
Citation K0281. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install proper backup exit lighting.
CMS lists it as corrected on November 3, 2025.
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on November 3, 2025.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on November 3, 2025.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on November 3, 2025.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on November 3, 2025.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on November 3, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on November 3, 2025.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on November 3, 2025.
Health inspection on July 15, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on August 7, 2025.
CMS update of February 26, 2025
Star rating
The CMS health inspection star rating changed from 4 of 5 to 5 of 5.
Health inspection on September 13, 2024
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on October 18, 2024.
CMS has cited this home for F0812 2 times since 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on October 18, 2024.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on October 18, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 18, 2024.
Fire safety inspection on September 13, 2024
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation E0015. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Address subsistence needs for staff and patients.
CMS lists it as corrected on October 1, 2024.
CMS has cited this home for E0015 2 times since 2023.
Citation E0034. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide a means of sharing information on occupancy/needs.
CMS lists it as corrected on October 1, 2024.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on October 1, 2024.
Citation K0362. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
CMS lists it as corrected on September 17, 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on October 1, 2024.
CMS has cited this home for K0712 2 times since 2023.
Citation K0355. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on October 1, 2024.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on October 1, 2024.
CMS has cited this home for K0511 2 times since 2023.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5.
Health inspection on September 29, 2023
9 citationsCMS lists this as a standard inspection.
Show the 9 citations
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 14, 2023.
Citation F0637. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident when there is a significant change in condition
CMS lists it as corrected on November 14, 2023.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on November 14, 2023.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on November 14, 2023.
Citation F0676. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on November 14, 2023.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on November 14, 2023.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on November 14, 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 14, 2023.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on November 14, 2023.
Fire safety inspection on September 29, 2023
5 citationsCMS lists this as a standard inspection.
Show the 5 citations
Citation E0015. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Address subsistence needs for staff and patients.
CMS lists it as corrected on October 31, 2023.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on October 31, 2023.
Citation K0511. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on October 31, 2023.
Citation K0712. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on October 31, 2023.
Citation K0100. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet other general requirements.
CMS lists it as corrected on October 31, 2023.
CMS star ratings
- 5 of 5CMS overall star rating
- 4 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (206) 842-4765
- Last standard health inspection
- November 17, 2025 (11 months ago)
- Certified beds
- 58
- Residents per day, on average
- 44
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Eagle Harbor Healthcare LLC
- Chain
- The Ensign Group
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Washington average (22 vs 50).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- DE ORO, THOMASOperational/managerial control · not applicable · since 04/01/2015
- KRETCHMAR, JOSHUAOperational/managerial control · not applicable · since 12/01/2021
Questions
When was Bainbridge Island Health & Rehab Center last inspected?
CMS lists November 17, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Bainbridge Island Health & Rehab Center have?
CMS lists 22 health citations since September 29, 2023. CMS also calls these deficiencies.
Has Bainbridge Island Health & Rehab Center been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Bainbridge Island Health & Rehab Center?
Its CMS overall star rating is 5 of 5.
Is Bainbridge Island Health & Rehab Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.