Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
BAILEY-BOUSHAY HOUSE
SEATTLE, WA · 35 certified beds · Last Life Safety survey May 5, 2025
CMS Certification Number 505476 · first certified June 1992
Ownership
Operated by COMMONSPIRIT HEALTH · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WA
36 citations — more than 64% 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 5 citations; the earlier surveys in the window averaged 15.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (April 2026 to July 2026), and past the point by which nine in ten WA facilities have been surveyed. This facility’s last Life Safety survey was May 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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3 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
15 of the 36 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)
4 physical-environment citations 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 36 Life Safety citations above. The Physical Environment Index
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 | 36 |
| Median facility in WA | 31 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 1, 2023 | 19 |
| May 20, 2024 | 12 |
| May 5, 2025 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-05-05 |
| E-0007 | Address patient/client population and determine types of services needed. | 2 | 2024-05-20 |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | 2 | 2025-05-05 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2024-05-20 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 2 | 2025-05-05 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-05-05 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 2 | 2024-05-20 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2024-05-20 |
What the citations cover
- Emergency Preparedness Deficiencies 15
- Gas, Vacuum, and Electrical Systems Deficiencies 9
- Smoke Deficiencies 7
- Miscellaneous Deficiencies 3
- Other 2
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 15 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 9 |
| Smoke Deficiencies | 7 |
| Miscellaneous Deficiencies | 3 |
| Services Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 5, 2025 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 10, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 4, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 4, 2025) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (June 4, 2025) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (June 4, 2025) |
May 20, 2024 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (July 11, 2024) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (July 11, 2024) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (July 11, 2024) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (July 11, 2024) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (July 11, 2024) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (July 11, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (July 11, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 11, 2024) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (July 11, 2024) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (July 11, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 11, 2024) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (July 11, 2024) |
March 1, 2023 — 19 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (April 25, 2023) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (April 25, 2023) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (March 28, 2023) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (March 28, 2023) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (May 16, 2023) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (April 25, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (March 28, 2023) |
| E-0042 | Meet the requirements of an integrated health system. | Deficient, Provider has date of correction (March 28, 2023) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (March 28, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 28, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (May 16, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (March 28, 2023) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (May 16, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (March 28, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Waiver has been granted (May 16, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Waiver has been granted (May 16, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Waiver has been granted (May 16, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Waiver has been granted (May 16, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (March 28, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.