01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-11-17 | 6 | 2025-11-17 | 9 |
| Cycle 2 | 2024-09-13 | 5 | 2024-09-13 | 7 |
| Cycle 3 | 2023-09-29 | 9 | 2023-09-29 | 5 |
CMS CCN 5053252026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Bainbridge Island Health & Rehab Center
835 Madison Avenue North · Bainbridge Island, WA 98110 · Kitsap County
Certified beds58CMS provider file
Recent citation rows41current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
41 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-07-01 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has plan of correction · 2026-08-01 · complaint2026-05-06 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2026-06-01 · complaint2025-11-17 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2025-11-032025-11-17 · HEALTHF0605Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Correction field: Deficient, Provider has date of correction · 2025-12-262025-11-17 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2025-12-262025-11-17 · HEALTHF0679Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Correction field: Deficient, Provider has date of correction · 2025-12-262025-11-17 · HEALTHF0804Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2025-12-262025-11-17 · FIREK0281Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install proper backup exit lighting.
Correction field: Deficient, Provider has date of correction · 2025-11-032025-11-17 · FIREK0321Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-11-032025-11-17 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-11-032025-11-17 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-11-032025-11-17 · FIREK0761Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2025-11-032025-11-17 · FIREK0914Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Correction field: Deficient, Provider has date of correction · 2025-11-032025-11-17 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-11-032025-11-17 · FIREK0920Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2025-11-032025-07-15 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-08-07 · complaint2024-09-13 · FIREE0015Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Address subsistence needs for staff and patients.
Correction field: Deficient, Provider has date of correction · 2024-10-012024-09-13 · FIREE0034Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Provide a means of sharing information on occupancy/needs.
Correction field: Deficient, Provider has date of correction · 2024-10-012024-09-13 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2024-10-012024-09-13 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-10-182024-09-13 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2024-10-182024-09-13 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-10-182024-09-13 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-10-182024-09-13 · FIREK0355Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2024-10-0103 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- DE ORO, THOMASIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2015
- KRETCHMAR, JOSHUAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 12/01/2021
- BURNAM, SOONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/02/2014
- FARNSWORTH, STEPHENIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2023
- KEETCH, CHADIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2011
- DE ORO, THOMASIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2015
- KRETCHMAR, JOSHUAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2021
- PORT, BARRYIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 09/12/2025
- BAINBRIDGE HEALTH HOLDINGS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2015
- STANDARD BEARER HEALTHCARE OP LPOrganization · ADP OF THE SNFNOT APPLICABLE · since 01/01/2022
- THE ENSIGN GROUP INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 01/01/2022
- DE ORO, THOMASIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/01/2015
- KRETCHMAR, JOSHUAIndividual · ADP OF THE SNFNOT APPLICABLE · since 12/01/2021
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.91per resident day
RN hours1.27per resident day
Weekend nurse hours3.50per resident day
Staff turnover23.3%CMS reported field
06 / LOCAL RECORDS
Open the Washington ledger →Other published facilities nearby
No second facility in the same city met the directory rule.