Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
BAINBRIDGE ISLAND HEALTH & REHAB CENTER
BAINBRIDGE ISLAND, WA · 58 certified beds · Last Life Safety survey November 17, 2025
CMS Certification Number 505325 · first certified December 1988
Ownership
Operated by THE ENSIGN GROUP · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WA
21 citations — more than 26% of the 193 certified nursing homes in WA. Compared within WA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 9 citations; the earlier surveys in the window averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens November 2026 — about 1 month from now. This facility’s last Life Safety survey was November 2025. Facilities in WA are typically surveyed 12–15 months after the last one (median 13), measured over 320 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
6 of the 21 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 21 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in WA, and nationally. Surveyors differ markedly between states, so the WA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 21 |
| Median facility in WA | 31 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 29, 2023 | 5 |
| September 13, 2024 | 7 |
| November 17, 2025 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | 3 | 2025-11-17 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2024-09-13 |
| E-0015 | Address subsistence needs for staff and patients. | 2 | 2024-09-13 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-09-13 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2025-11-17 |
| K-0100 | Meet other general requirements. | 1 | 2023-09-29 |
| E-0034 | Provide a means of sharing information on occupancy/needs. | 1 | 2024-09-13 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-11-17 |
What the citations cover
- Emergency Preparedness Deficiencies 6
- Smoke Deficiencies 5
- Miscellaneous Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Other 4
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 6 |
| Smoke Deficiencies | 5 |
| Miscellaneous Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Services Deficiencies | 2 |
| Egress Deficiencies | 1 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 17, 2025 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (November 3, 2025) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (November 3, 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. | Deficient, Provider has date of correction (November 3, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 3, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 3, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (November 3, 2025) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (November 3, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 3, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 3, 2025) |
September 13, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (October 1, 2024) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (October 1, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (October 1, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (October 1, 2024) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (September 17, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 1, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 1, 2024) |
September 29, 2023 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (October 31, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (October 31, 2023) |
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (October 31, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 31, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 31, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.