Bainbridge Island Health & Rehab Center

Name: Bainbridge Island Health & Rehab Center
Address: 835 MADISON AVENUE NORTH, Bainbridge Island, WA, 98110, US
Telephone: 2068424765

835 Madison Avenue North, Bainbridge Island, WA 98110 · Kitsap County · 58 certified beds · avg 42 residents/day · certified since Dec 1, 1988

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

5/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.77

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★★5/5 · CMS overall rating: 5/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (20)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jul 1, 2026	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
May 6, 2026	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Nov 17, 2025	D · Potential for harm, one-off	The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
Nov 17, 2025	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Nov 17, 2025	D · Potential for harm, one-off	The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Nov 17, 2025	D · Potential for harm, one-off	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Jul 15, 2025	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Sep 13, 2024	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Sep 13, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Sep 13, 2024	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Sep 13, 2024	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Sep 29, 2023	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Sep 29, 2023	D · Potential for harm, one-off	The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way.
Sep 29, 2023	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Sep 29, 2023	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Sep 29, 2023	D · Potential for harm, one-off	The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Sep 29, 2023	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Sep 29, 2023	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Sep 29, 2023	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Sep 29, 2023	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (4 → 4).

Year	Citations	Worst severity that year
2023	9	E
2024	4	E
2025	5	D
2026	2	D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Washington avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.77	4.24	3.95	bottom 32% in Washington; bottom 50% in the U.S.
Registered Nurse hours	1.22	0.91	0.69	top 14% in Washington; top 9% in the U.S.
Weekend total nurse staffing	3.37	3.69	3.50	bottom 43% in Washington; top 49% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.98	0.67	0.48	top 11% in Washington; top 6% in the U.S.
Total nursing staff turnover (%)	23.3	45.1	45.8	top 4% in Washington; top 5% in the U.S.
RN turnover (%)	15.4	45.4	42.9	top 3% in Washington; top 9% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.91, RN 1.27, weekend 3.50. Staffing rating: 5/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Bainbridge Health Holdings LLC	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2015
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	12/02/2014
De Oro, Thomas	Individual	Managing Control - Governing Body	NOT APPLICABLE	04/01/2015
De Oro, Thomas	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2015
De Oro, Thomas	Individual	ADP of the SNF	NOT APPLICABLE	04/01/2015
Farnsworth, Stephen	Individual	Corporate Officer	NOT APPLICABLE	01/01/2023
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
Kretchmar, Joshua	Individual	Managing Control - Governing Body	NOT APPLICABLE	12/01/2021
Kretchmar, Joshua	Individual	Operational/Managerial Control	NOT APPLICABLE	12/01/2021
Kretchmar, Joshua	Individual	ADP of the SNF	NOT APPLICABLE	12/01/2021
Port, Barry	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	09/12/2025
Standard Bearer Healthcare Op LP	Organization	ADP of the SNF	NOT APPLICABLE	01/01/2022
The Ensign Group INC	Organization	ADP of the SNF	NOT APPLICABLE	01/01/2022

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
"Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
"Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
"Could I join residents for a meal to see the food quality and temperature for myself?"
"What systems do you use to prevent medication errors, and what happens when one occurs?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Bremerton Trails Post Acute	6.1 mi	Bremerton, WA	★☆☆☆☆	1/5	SFF
Belmont Terrace	6.1 mi	Bremerton, WA	★★★☆☆	2/5
Avamere Rehabilitation at Park West	6.8 mi	Seattle, WA	★★☆☆☆	2/5
Washington Veteran Home-Retsil	7.2 mi	Pt Orchard, WA	★★★★☆	3/5
Queen Anne Healthcare	8.0 mi	Seattle, WA	★★★★★	5/5
Northwoods Lodge	8.0 mi	Silverdale, WA	★★★★★	4/5
Port Washington Post Acute	8.1 mi	Bremerton, WA	★☆☆☆☆	1/5
Columbia Lutheran Home	8.2 mi	Seattle, WA	★★★★☆	3/5
Providence Mount St Vincent	8.3 mi	Seattle, WA	★★★☆☆	2/5
Ballard Center	8.3 mi	Seattle, WA	★★☆☆☆	2/5

Compare this facility with the 3 closest →

All facilities in Bainbridge Island →

Facility data as of CMS processing date 2026-08-01. CCN 505325.

The Care File

Visit checklist — Bainbridge Island Health & Rehab Center

835 Madison Avenue North, Bainbridge Island, WA 98110 · 2068424765

Health inspection rating 5/5 · CMS overall 5/5· Fines (3y): $0

Questions for the administrator:

☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
☐ "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
☐ "Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
☐ "Could I join residents for a meal to see the food quality and temperature for myself?"
☐ "What systems do you use to prevent medication errors, and what happens when one occurs?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 505325 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)