Regency Harmony House Rehab & Nursing
100 River Plaza, Brewster, WA 98812 · For profit - Limited Liability company · 54 certified beds · (509) 689-2546 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0602), cited Jul 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 21.2% | 14.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.5% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.0% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.2% | 1.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 11.7% | 17.7% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.7% | 2.6% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 18.5% | 17.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 12.2% | 12.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.5% | 93.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.0% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.3% | 22.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.1% | 15.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.1% | 1.3% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 67.9% | 82.0% | 79.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.52 | 1.33 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.30 | 1.52 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
37.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 49 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 51.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 29 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 42% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 37.5%CMS range 26.7–48.5 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 6.2–14.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 51.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 27.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 17.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 3.7–12.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.18 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 54 beds and averages 49.2 residents a day — about 91% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.70 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.53 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.89 hrs/resident/day on weekends vs 4.03 on weekdays — 28% thinner on weekends — a notable drop. RN hours go from 0.93 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 28% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.
- Potential for harm · D2025-11-23 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes who protected and promoted resident rights under federal and state law and regulations) of discharges and/or transfers, as required for 1 of 3 sampled residents (Resident 53), reviewed for hospitalization and discharges. This failure placed residents at risk of not having an advocate during and after discharge.Findings included .Review of admission assessment dated [DATE], documented Resident 53 had diagnoses including a stroke, dementia, and depression. Resident 53 was cognitively intact and able to make their needs known. Review of progress note dated 09/12/2025 at 5:38 PM documented Resident 53 discharged home with their family member. During an interview on 11/23/2025 at 12:49 PM, Staff G, Health Information Director, stated they did not notify the Ombudsman when a resident discharged home, only when they went to the hospital. Staff G stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-23 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to incorporate recommended behavioral health interventions into the comprehensive care plan timely for 1 of 5 sampled residents (Resident 3) reviewed for PASRR recommendations (Preadmission Screening and Resident Review, a behavioral health evaluation that identified psychosocial needs of residents). This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of quarterly assessment dated [DATE], documented Resident 3 had diagnoses including anxiety, depression and a paranoid personality disorder (a pattern of distrust and suspicion of others). The assessment further showed the resident had moderate cognitive impairments.Review of Level II PASRR (a more in-depth assessment conducted after a Level I screening suggested an individual may have a serious mental illness) evaluation dated 11/06//2025 recommended the following: -bed rails to enhance Resident 3's safety-bed in low…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to follow provider orders for 1 of 5 sampled residents (Resident 4) reviewed for nutrition. Specifically, Resident 4 had orders for a fluid restriction, and their oral fluid intake was not fully monitored. This failure placed the resident at risk for health consequences. Findings included . The 09/25/2025 quarterly assessment documented Resident 4 had diagnoses including heart failure (heart not strong enough to pump blood well enough to meet the body's needs), atrial fibrillation (irregular and abnormal heartbeat) and high blood pressure. Resident 4 had moderate cognitive impairment and was able to verbalize their needs.A 01/09/2025 provider order documented Resident 4 was on a 2000 milliliter (ml) fluid restriction. Nursing staff was to include the total amount of fluids consumed for each shift including nursing administered medications, meals and free fluid if provided.Review of the 03/07/2025 dehydration care plan documented Resident 4 was on a fluid restriction related to heart failure. The care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-23 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure residents were given their medications as ordered for 1 of 5 sampled residents (Resident 3) reviewed for medication management. This failure placed residents at risk of medical complications.Findings included . The 11/15/2025 quarterly assessment documented Resident 3 had diagnoses including depression, anxiety and heart failure. The assessment further showed the resident had moderate cognitive impairments. The 08/11/2025 care plan instructed nursing to give Resident 3 their medications as ordered.A review of the November 2025 Medication Administration Record (MAR), showed:-Acetaminophen 500 milligrams (mg) two tablets three times a day related to chronic pain. The entry on 11/01/2025 was blank and 10/07/2025 and 11/02/2025 had a code 9 entered, which indicated there was a progress note. The progress notes on both of those days stated the resident was asleep.-Amiodarone 200 mg twice daily related to atrial fibrillation (an irregular heartbeat). The entry on 11/01/2025 was blank and 10/07/2025 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-23 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to perform hand hygiene when indicated during 1 of 1 wound care observations. Additionally, the facility failed to ensure enhanced barrier precautions (EBP, use of personal protective equipment such as disposable gowns and gloves when providing high contact types of care for residents with drains, tubes, or wounds) were implemented and followed when indicated for 2 of 3 sampled residents (Residents 1 and 23), reviewed for infection control. This failure placed residents at risk for potential unintended health consequences, the potential spread of infectious diseases or organisms resistant to antibiotics, and diminished quality of life.Findings included.According to The Centers for Disease Control (CDC) Implementation of Personal Protective Equipment (PPE- gloves, disposable gowns, eye protection or masks) Use in Nursing Homes to prevent Spread of Multidrug-Resistant Organisms updated July 12, 2022, retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html recommended use of EBP as an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-30 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect 1 of 3 residents (Resident 2) reviewed for drug diversion (transfer of medication from the resident it was prescribed for to another person for unlawful use), from misappropriation of controlled medications (a drug or chemical that is regulated due to its potential for abuse or dependence). This failure placed residents at risk for unmet care needs, on-going misappropriation of medication, and a diminished quality of life.Review of a facility incident report dated 07/11/2025 showed that on 07/11/2025 Staff C, RN, reported to Staff A, Administrator, that on 06/14/2025 during shift exchange, Staff D, RN, and Staff C, RN were counting controlled medications when Staff C noticed a clear, 30 milliliter (about two tablespoons), medication cup containing some liquid in the top medication cart drawer. Staff C reported they picked up the medication cup to dispose of it when Staff D, took the medication cup, with the liquid, from them, stating No. That's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-30 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were free of chemical restraints for 2 of 3 residents (Resident 1 and 3) reviewed for unnecessary medications. This deficient practice placed residents at risk of experiencing unnecessary side effects such as sedation, decline in physical functioning, and placed residents at risk of experiencing an undignified life.Review of a facility incident report dated 07/11/2025 showed that on 07/11/2025 Staff C, Registered Nurse (RN), reported to Staff A, Administrator, that on 06/14/2025 while counting controlled medications (a drug or chemical that is regulated due to its potential for abuse or dependence) and making sure everything was in order in the nurse medication cart, Staff C had found a clear, plastic, medication cup in the top drawer of the nurse medication cart with a small amount of clear liquid in the cup. Staff C then went to dispose of the unmarked medication cup when Staff D, RN, intervened, took the medication cup…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-18 · tag F0555 — isolatedHonor the resident's right to choose his or her attending physician.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1), reviewed for choices, was afforded the right to choose their own attending physician. This failure placed the resident at risk for a diminished quality of care. Findings included Review of Resident 1's electronic medical record showed they admitted to the facility on [DATE] from a hospital with diagnoses including repair of right upper leg fracture with revision of a total hip replacement after a fall. The resident had a large surgical incision (about 16 inches long) related to the fracture repair. In a telephone interview on 02/18/2025 at 12:16 PM with Collateral Contact 1 (CC1), they stated that they had requested the facility to contact Resident 1's Primary Care Physician (PCP) for orders and a history of the resident as they were familiar with the resident and their history, and were told by a facility nurse that they had to use the facility Physician, Staff D. CC 1 stated that they were not happy with this…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-11 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to implement their Abuse and Neglect Prohibition Policies and Procedures when they failed to report an allegation of abuse to the State Agency (SA) within the required timeframe and failed to complete a thorough investigation for 1 of 2 sampled residents (Resident 23) reviewed for abuse. This failure placed the resident and other residents at risk for repeated abuse. Findings included . The 10/2022 revised facility policy titled Abuse/Neglect/Misappropriation/Exploitation documented the facility protected residents from abuse and neglect by implementing procedures designed to prevent, identify, report, and investigate allegations of abuse and neglect. The policy instructed staff to report immediately to the Abuse Hotline (a SA), but no later than 2 hours after an allegation of abuse or neglect was made if the events that caused the allegation resulted in serious bodily injury, and no later than 24 hours if the events that caused the allegation did not involve abuse or result in serious bodily injury. The policy documented…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-11 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to assess, identify triggers that might prompt a recall of previous traumatic events, and develop care planned goals and interventions for a resident who was a trauma survivor for 1 of 2 sampled residents (Resident 7) reviewed for trauma informed care. This failure placed the resident at risk for re-traumatization, psychological harm and a diminished quality of life. Findings included . The 10/2022 revised facility policy titled Trauma Informed Care described a traumatic event as either a single or enduring repeated or multiple experiences that completely overwhelmed a resident's ability to cope or integrate ideas and emotions involved in that experience. Trauma-Informed Care promoted an environment of healing and recovery rather than practices that might inadvertently re-traumatize a resident. Staff were instructed to screen residents for trauma-informed care needs upon admission and identify the triggers and history of trauma in residents, with the help of family/friends/responsible parties. A care plan was to be developed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · Dcited before2024-09-11 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to adequately date food items and ensure expired food items were disposed of when indicated during 1 of 1 inspections in the main kitchen. This failure placed the residents at risk for food-borne illnesses. Findings included . Review of the undated facility guideline titled Dry, Refrigerated and Freezer Storage Chart documented proper storage times for opened and unopened dry, refrigerated and frozen food items. The guideline instructed the staff to follow manufacturer's directions and expiration dates and those expiration dates superseded the guidelines. The guideline instructed that once a food item was opened it was not to be stored longer than the total unopened time. An observation and interview in the facility's kitchen on 09/03/24 at 11:15 AM was completed with Staff C, Dietary Services Manager with the following findings: <REFRIGERATED GOODS> 1. A bag of Caesar salad was dated 08/27 but had no clear indication if that was the date the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-18 · tag F0761 — failed to label and store drugs safely — patternEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to appropriately label, and store refrigerated controlled substances in a permanently affixed compartment as required in 1 of 1 medication rooms observed for medication storage. In addition, the facility failed to maintain records to reconcile refrigerated emergency kit controlled medications in 1 of 1 medication rooms. This failure placed the facility at risk of controlled drug diversion. Findings included . Review of pharmacy policy titled, Inventory Control of Controlled Substances, dated 01/2022, showed the facility should maintain a written record of all controlled substance medications transferred from the pharmacy to the facility's emergency medication kit. The policy further showed facility staff should count all medications with risk for abuse or diversion at each change of shift or at least once daily and document on a controlled substance count sheet. During observation of the medication room refrigerator on 10/13/2023 at 10:42 AM with Staff C, Resident Care Manager (RCM), a locked black metal box was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-18 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to consistently maintain dish machine temperatures which placed all residents at increased risk for foodborne illness. Findings included . During an observation of the kitchen on 10/17/2023 at 12:21, Staff E, Dietary Manager, stated the dishwasher was a low temperature dishwasher, which must sanitize the dishes at 120 degrees or above. The temperature logs for October 2023 showed the temperatures were below 120 degrees on 16 different occasions. Staff E stated that maintenance was informed each time the dishwasher was below 120 degrees, and the temperature was fixed. Staff E was unable to provide documentation showing the temperature had been fixed and what the new temperature was afterward. During an interview on 10/17/2023 at 1:35 PM, Staff F, Maintenance Assistant, stated they are notified when the temperature of the dishwasher was low. When Staff F looked at the temperature log for October 2023, they stated they were unaware that the temperature had dropped below 120 degrees that often. Staff F stated that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure oxygen tubing was appropriately maintained and changed regularly, according to professional standards of practice for 1 of 2 sampled residents (Resident 38) These failures placed the residents at risk for contact with contaminated care equipment, potential respiratory infections, and respiratory distress. Findings included . Per the 12/09/2022 admission assessment, Resident 38 admitted to the facility with heart failure and chronic obstructive pulmonary disease (a group of lung diseases that block airflow, making it difficult to breathe) and required oxygen due to those conditions. Review of the physician orders showed on 12/09/2022, the resident had been prescribed oxygen to be used continuously due to the diagnoses listed. The most recent physician order dated 06/20/2023 directed nursing staff to change the oxygen tubing weekly and as needed. On 10/11/2023 at 11:48 AM, Resident 38's oxygen tubing on their walker was dated 08/02/2023. On 10/12/2023 at 8:58 AM, Resident 38 was observed lying in bed,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to consistently and comprehensively assess and monitor 1 of 3 residents (Resident 1) with an inserted catheter (flexible tubing inserted into the body to remove fluid) or surgical drain (tubing used to remove excess fluids from the body). Failure to consistently assess and monitor Resident 1's surgical drain placed the resident at risk for infection and possible medical complications. Findings included . Resident 1 was admitted to the facility on [DATE] after having a surgical drain placed in their right lower back to drain an abscess (collection of pus that has built up within the tissue of the body) near their right kidney. Review of Resident 1's hospital Discharge summary dated [DATE] and titled What to do Next, Instructions From Your Doctor, stated to measure drain output daily, track it and bring when you see [Urologist] (a doctor who specializes in treatment of the function of the urinary system). Record review of Resident 1's care plan showed a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to REGENCY PACIFIC MANAGEMENT — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.9 | +1.1 vs chain |
| Health inspection | 5 of 5 | 3.7 | +1.3 vs chain |
| Staffing | 4 of 5 | 4.0 | ≈ chain avg |
| Quality measures | 2 of 5 | 3.6 | -1.6 vs chain |
The other 26 homes this chain runs (chain average 3.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| REGENCY PACIFIC MANAGEMENT LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 04/01/2010 |
| TRETWOLD, JERRY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 06/01/2016 |
CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $692K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Washington Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 505430. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-23, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.