Bainbridge Island Health & Rehab Center — nursing home in Bainbridge Island, WA

Facility type: Nursing home · SNF / NF
CMS provider type: Medicare and Medicaid
Certified beds: 58 CMS-certified beds (not state-licensed beds)
Licensed beds: State licensure is issued by the state survey agency. State license records are not yet ingested for this facility; the federal CMS certification is shown instead.
Average residents per day: 44.0 CMS, MDS-derived
CMS Certification Number: 505325
Certification status: Active CMS certification Verified
First approved (Medicare/Medicaid): Dec 1, 1988
Ownership type: For profit - Limited Liability company
Operator (legal business name): Eagle Harbor Healthcare LLC
CMS chain: The Ensign Group 347 facilities
Phone: (206) 842-4765
Resident & family council: Resident
Sprinklers in all required areas: Yes
Official profile: Medicare Care Compare ↗

Inspection record · CMS window

Verified

Inspections

10

latest Aug 20, 2026

Citations

43

22 health · 21 fire

Harm or worse

0

no immediate jeopardy

Severity	Isolated	Pattern	Widespread
Immediate jeopardy	J·	K·	L·
Actual harm	G·	H·	I·
Potential harm	D21	E6	F16
Minimal	A·	B·	C·

CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.

CMS Five-Star ratings

Federal · CMS

Overall

Health inspections

Staffing

Quality measures

Penalties · about the last 3 years

Fines

0

$0

Payment denials

0

Latest

—

Federal certification

Federal · CMS

Authority: Centers for Medicare & Medicaid Services (CMS), surveyed by the state survey agency
CCN: 505325
Program: Medicare and Medicaid
Medicare (SNF): Certified
Medicaid (NF): Certified
Certified beds: 58
First approved: Dec 1, 1988
Located in a hospital: No
Status: Active CMS certification as of CMS release Oct 1, 2026
Evidence: Verified

State license

State licensure is issued by the state survey agency. State license records are not yet ingested for this facility; the federal CMS certification is shown instead. State coverage for Washington.

Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.

CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.

Date	Domain	Survey types	Citations	Most severe	Open
Aug 20, 2026	Health	Health Complaint	2	Potential harm	2	Open →
Jul 1, 2026	Health	Health Complaint	1	Potential harm	—	Open →
May 6, 2026	Health	Health Complaint	1	Potential harm	—	Open →
Nov 17, 2025	Fire safety	Fire Safety Standard	9	Potential harm	—	Open →
Nov 17, 2025	Health	Health Standard	4	Potential harm	—	Open →
Jul 15, 2025	Health	Health Complaint	1	Potential harm	—	Open →
Sep 13, 2024	Fire safety	Fire Safety Standard	7	Potential harm	—	Open →
Sep 13, 2024	Health	Health Standard	4	Potential harm	—	Open →
Sep 29, 2023	Fire safety	Fire Safety Standard	5	Potential harm	—	Open →
Sep 29, 2023	Health	Health Standard	9	Potential harm	—	Open →

Enforcement

Penalties

Civil money penalties and denials of payment for new admissions, as published by CMS (about the last three years). Amounts may change on appeal.

No fines or payment denials in the CMS Penalties file for this CCN.

Scope × severity

Severity	Isolated	Pattern	Widespread
Immediate jeopardy	J·	K·	L·
Actual harm	G·	H·	I·
Potential harm	D21	E6	F16
Minimal	A·	B·	C·

By concept

Date	Tag	Deficiency	Scope / severity	Correction	Flags
Aug 20, 2026	F-0658	Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care	E · Potential harm Pattern	Plan of correction, not yet verified Sep 25, 2026	Complaint
Aug 20, 2026	F-0880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention	E · Potential harm Pattern	Plan of correction, not yet verified Sep 25, 2026	Complaint
Jul 1, 2026	F-0684	Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Aug 1, 2026	Complaint
May 6, 2026	F-0600	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Jun 1, 2026	Complaint
Nov 17, 2025	E-0039	Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness	F · Potential harm Widespread	Corrected Nov 3, 2025
Nov 17, 2025	K-0281	Install proper backup exit lighting. Egress Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Nov 3, 2025
Nov 17, 2025	K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Nov 3, 2025
Nov 17, 2025	K-0345	Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Nov 3, 2025
Nov 17, 2025	K-0353	Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Nov 3, 2025
Nov 17, 2025	K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Nov 3, 2025
Nov 17, 2025	K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Nov 3, 2025
Nov 17, 2025	K-0918	Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Nov 3, 2025
Nov 17, 2025	K-0920	Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Nov 3, 2025
Nov 17, 2025	F-0605	Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Dec 26, 2025
Nov 17, 2025	F-0658	Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Dec 26, 2025
Nov 17, 2025	F-0679	Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Dec 26, 2025
Nov 17, 2025	F-0804	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration	D · Potential harm Isolated	Corrected Dec 26, 2025
Jul 15, 2025	F-0760	Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management	D · Potential harm Isolated	Corrected Aug 7, 2025	Complaint
Sep 13, 2024	E-0015	Address subsistence needs for staff and patients. Emergency Preparedness Deficiencies · Emergency preparedness	F · Potential harm Widespread	Corrected Oct 1, 2024
Sep 13, 2024	E-0034	Provide a means of sharing information on occupancy/needs. Emergency Preparedness Deficiencies · Emergency preparedness	F · Potential harm Widespread	Corrected Oct 1, 2024
Sep 13, 2024	E-0039	Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness	F · Potential harm Widespread	Corrected Oct 1, 2024
Sep 13, 2024	K-0355	Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Oct 1, 2024
Sep 13, 2024	K-0362	Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Smoke Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Sep 17, 2024
Sep 13, 2024	K-0511	Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Oct 1, 2024
Sep 13, 2024	K-0712	Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Oct 1, 2024
Sep 13, 2024	F-0684	Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Oct 18, 2024
Sep 13, 2024	F-0695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Oct 18, 2024
Sep 13, 2024	F-0812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration	E · Potential harm Pattern	Corrected Oct 18, 2024
Sep 13, 2024	F-0880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention	D · Potential harm Isolated	Corrected Oct 18, 2024
Sep 29, 2023	E-0015	Address subsistence needs for staff and patients. Emergency Preparedness Deficiencies · Emergency preparedness	F · Potential harm Widespread	Corrected Oct 31, 2023
Sep 29, 2023	E-0039	Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness	F · Potential harm Widespread	Corrected Oct 31, 2023
Sep 29, 2023	K-0100	Meet other general requirements. Construction Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Oct 31, 2023
Sep 29, 2023	K-0511	Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Oct 31, 2023
Sep 29, 2023	K-0712	Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Oct 31, 2023
Sep 29, 2023	F-0637	Assess the resident when there is a significant change in condition Resident Assessment and Care Planning Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Nov 14, 2023
Sep 29, 2023	F-0641	Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Nov 14, 2023
Sep 29, 2023	F-0657	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Nov 14, 2023
Sep 29, 2023	F-0676	Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Nov 14, 2023
Sep 29, 2023	F-0677	Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Nov 14, 2023
Sep 29, 2023	F-0757	Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management	D · Potential harm Isolated	Corrected Nov 14, 2023
Sep 29, 2023	F-0761	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. Pharmacy Service Deficiencies · Medication management	D · Potential harm Isolated	Corrected Nov 14, 2023
Sep 29, 2023	F-0812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration	E · Potential harm Pattern	Corrected Nov 14, 2023
Sep 29, 2023	F-0842	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Nov 14, 2023

“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.

Five-Star ratings

Federal · CMS

Overallstate 3.3

Health inspectionsstate 2.8

Staffingstate 3.7

Quality measuresstate 4.1

Long-stay QM

Short-stay QM

CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.

Nurse staffing · hours per resident per day

Total nurse staffing3.77

State avg 4.42US avg 3.90

Registered nurse (RN)1.14

State avg 0.99US avg 0.69

Licensed practical nurse0.29

State avg 0.74US avg 0.86

Nurse aide2.34

State avg 2.68US avg 2.35

Weekend total nurse3.39

State avg 3.82US avg 3.43

Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.52 (case-mix index 1.50).

Staff turnover

Total nursing staff turnover18.9%

State avg 43.9%US avg 45.3%

Registered nurse turnover16.7%

State avg 43.8%US avg 42.5%

Administrators who left0

State avg 1US avg 1

Health survey score

Cycle 1 standard survey: Nov 17, 2025
Cycle 1 health score: 40
Total weighted score: 36

Operating entity

Eagle Harbor Healthcare LLC

CMS legal business name of the certified provider. Operates this facility only.

VerifiedLinked by exact legal name

CMS chain

The Ensign Group

347 facilities in 17 states. CMS chain ID 507.

VerifiedAssigned by CMS

Chain average overall rating (CMS): 3.3

Ownership disclosures

Disclosures

13

Organizations

3

Individuals

10

CMS Ownership file

All disclosed roles

Operator, owners, managers, officers and lenders are distinct roles and are never flattened into one entity. Organizations link across facilities by exact normalized legal name; individuals are listed per facility only.

Name	Type	Role (Carefield group)	CMS role text	Share	Since
Barry Port	Individual	Partner	INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF	not provided	Sep 12, 2025
Thomas De Oro	Individual	Operational / managerial control	MANAGING CONTROL - GOVERNING BODY	not provided	Apr 1, 2015
Joshua Kretchmar	Individual	Operational / managerial control	MANAGING CONTROL - GOVERNING BODY	not provided	Dec 1, 2021
Thomas De Oro	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Apr 1, 2015
Joshua Kretchmar	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Dec 1, 2021
Soon Burnam	Individual	Corporate officer / director	CORPORATE OFFICER	not provided	Dec 2, 2014
Stephen Farnsworth	Individual	Corporate officer / director	CORPORATE OFFICER	not provided	Jan 1, 2023
Chad Keetch	Individual	Corporate officer / director	CORPORATE OFFICER	not provided	Mar 1, 2011
Bainbridge Health Holdings LLC	Organization	Additional disclosable party	ADP OF THE SNF	not provided	May 1, 2015
Standard Bearer Healthcare Op LP	Organization	Additional disclosable party	ADP OF THE SNF	not provided	Jan 1, 2022
The Ensign Group Inc	Organization	Additional disclosable party	ADP OF THE SNF	not provided	Jan 1, 2022
Thomas De Oro	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Apr 1, 2015
Joshua Kretchmar	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Dec 1, 2021

Same chain in Washington

All 346 in chain →

Facility	Beds	Last inspection	Citations (window)	Fines
Park Manor Rehabilitation Ctr 1710 Plaza Way, Walla Walla, WA 99362 CCN 505074	99	May 15, 2026	401 harm	$28k
Pacific Care and Rehabilitation 3035 Cherry Street, Hoquiam, WA 98550 CCN 505081	72	Jul 9, 2026	19	—
Redmond Care and Rehabilitation Center 7900 Willows Road Northeast, Redmond, WA 98052 CCN 505181	139	Feb 13, 2026	46	—
The Oaks at Timberline 400 East 33rd Street, Vancouver, WA 98663 CCN 505206	85	Mar 5, 2026	37	—
Olympia Transitional Care and Rehabilitation 430 Lilly Road Northeast, Olympia, WA 98506 CCN 505243	113	Aug 13, 2026	641 harm4 open	—
Shoreline Health and Rehabilitation 2818 Northeast 145th Street, Seattle, WA 98155 CCN 505262	114	Mar 24, 2026	108	—
Belmont Terrace 560 Lebo Boulevard, Bremerton, WA 98310 CCN 505290	102	Mar 2, 2026	91	—
Beacon Hill Rehabilitation 128 Beacon Hill Drive, Longview, WA 98632 CCN 505294	67	May 21, 2026	271 harm	$25k

No building or property record is linked to this facility yet. Parcel, assessor and building-permit joins will be added only where a valid site match exists.

Coordinates as published by CMS.

Address: 835 Madison Avenue North, Bainbridge Island, WA 98110
ZIP: 98110
County: Kitsap County FIPS 53035
State: Washington
Urban / rural (CMS): Urban

Within ~25 km

Nearby nursing homes

Facility	Distance	Beds	Last inspection	Citations (window)	Fines
Bremerton Trails Post Acute 2701 Clare Avenue, Bremerton, WA 98310 CCN 505123SFF CandidateAbuse icon	9.8 km	125	Aug 27, 2026	1372 IJ5 harm2 open	$219k
Belmont Terrace 560 Lebo Boulevard, Bremerton, WA 98310 CCN 505290	9.9 km	102	Mar 2, 2026	91	—
Avamere Rehabilitation at Park West 1703 California Avenue Southwest, Seattle, WA 98116 CCN 505270	10.9 km	137	Mar 9, 2026	991 IJ1 harm	$30k
Washington Veteran Home-Retsil 1141 Beach Drive, Pt Orchard, WA 98366 CCN 505517	11.6 km	240	Jul 20, 2026	751 harm1 open	$24k
Queen Anne Healthcare 2717 Dexter Avenue North, Seattle, WA 98109 CCN 505204	12.8 km	120	Aug 3, 2026	51	—
Columbia Lutheran Home 4700 Phinney Avenue North, Seattle, WA 98103 CCN 505470	13.2 km	116	Jul 8, 2026	81	—
Providence Mount St Vincent 4831 35th Avenue Southwest, Seattle, WA 98126 CCN 505182Abuse icon	13.3 km	215	Aug 7, 2026	954 harm	$130k
Ballard Center 820 Northwest 95th Street, Seattle, WA 98117 CCN 505042	13.4 km	142	Jul 23, 2026	174	—

Source	Record	Facts	Evidence	Source release	Retrieved
CMS Provider Information US-CMS	505325	name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain	Verified	Oct 1, 2026	Nov 7, 2026
CMS Provider Information US-CMS	505325	ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only.	Verified	Oct 1, 2026	Nov 7, 2026

Record-level source links for CCN 505325

First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction