No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Regency Olympia Rehabilitation And Nursing Center

1811 East 22nd Avenue, Olympia, WA 98501 · For profit - Limited Liability company · 28 certified beds · (360) 943-0910 Medicare & Medicaid certified

Call the home — (360) 943-0910 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0605, F0609) — most recent Apr 20261 actual-harm citation$8,278 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,278 in federal fines (most recent 2025-01-13)
  • nursing-staff turnover (67%) runs well above the national median (45%)

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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1100 Eastside St SE · (360) 943-5127 · Call to confirm hours
Pharmacy
520 Cleveland Ave SE · (360) 943-7600 · Call to confirm hours
Grocery
2102 Capitol Way S · (360) 943-0590 · Call to confirm hours
Park
2500 Henderson Blvd SE · (360) 753-8380 · Typically dawn to dusk
Place of worship

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 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 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.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.7%14.2%15.4%better
Long-stay residents who lose too much weight3.9%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.0%0.9%better
Long-stay residents with a urinary tract infection1.9%1.6%2.0%typical
Long-stay residents with depressive symptoms11.5%17.7%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.0%2.6%3.3%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication18.5%12.4%18.9%typical
Long-stay residents with pressure ulcers3.6%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control4.0%22.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table20.5%15.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.3%1.3%1.4%worse
Short-stay residents given the seasonal flu vaccine71.6%82.0%79.4%typical
Short-stay residents rehospitalized after admission19.8%19.9%22.6%better
Short-stay residents with an outpatient ER visit2.2%13.4%12.0%better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

66.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 104 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

66.0%U.S. median 51.5%
Got home and stayed home
9.2%U.S. median 10.7%
Went back to hospital
81.6%U.S. median 56.6%
Met the expected recovery
0.57U.S. median 0.31
Therapy hours / resident / day
0.27hours / resident / day
Physical therapy
0.27hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 81.6% 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 49 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 0.57 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF66.0%CMS range 56.8–76.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.2%CMS range 6.3–14.010.7%Oct 2022–Sep 2024no 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 discharge81.6%56.6%Oct 2024–Sep 2025CMS 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 discharge73.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge79.6%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 4.1–11.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 2022–Sep 2024CMS 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

0.85
RN hours/ resident / day
0.86
LPN hours/ resident / day
2.85
Aide hours/ resident / day
4.56
Total nurse hours/ resident / day
0.79
RN hoursweekends
66.7%
Total nursing turnover
90.0%
RN turnover

How full it usually is: this home is certified for 28 beds and averages 22.9 residents a day — about 82% occupied, or roughly 5 beds typically open. It usually has some room. 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 4.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.85 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.85 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 3.98 hrs/resident/day on weekends vs 4.79 on weekdays — 17% thinner on weekends. RN hours go from 0.87 to 0.79 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 67% is well above 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

6
deficiencies at the latest standard inspection (2026-04-10)
15
at the previous standard inspection (2025-05-23)

Deficiencies are fewer than at the previous inspection — improving. 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.

ABCDEFGHIJKL

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.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · G2025-01-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 timely action was taken when a resident's indwelling urinary catheter (a small flexible tube inserted into the bladder to drain urine) showed abnormal urine characteristics indicating an infection for 1 of 1 sampled resident (Resident 1) reviewed for catheter care. This resulted in Resident 1 experiencing harm when the potential infection was not treated/evaluated timely and the resident required a transfer to the hospital where she was diagnosed with a kidney infection. This failure placed residents at risk of acquiring catheter associated infections, delay in care, pain and a diminished quality of life. Findings included . Review of the facility's Catheter Care Policy and Procedure, revised 04/2018, documented residents with long term indwelling catheter use will have care plan interventions developed to prevent complications including urinary tract infections and urethral irritation. Section 6 noted residents with indwelling urinary…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-24 · tag F0675 — failed to support quality of life — isolated
    Honor each resident's preferences, choices, values and beliefs.
    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 interviews and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 3 sampled residents (Resident 1) reviewed for quality of life. This failure placed residents at risk for compromised health outcomes and a diminished quality of life.Findings included. Resident 1 was admitted to the facility on [DATE] with multiple diagnosis to include a right hip fracture. The 5-day Minimum Data Set, an assessment tool, dated 02/20/2026 indicated Resident 1 was cognitively intact.Record review of Resident 1's skilled transfer orders dated 02/13/2026, showed physician orders to schedule a follow up appointment with the orthopedic provider for staple removal in two weeks.In an interview on 04/20/2026 at 11:19 AM, Resident 1 said that she had not been out to see the orthopedic surgeon since admission. Resident 1 said she had her staples in for a long time recently having them removed which was painful.Record review of Resident 1's electronic…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-10 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 provide care and services in a manner that promoted dignity related to uncovered indwelling urinary catheter (a tube inserted into the bladder that drains urine into a bag outside of the body) bags for 1 of 2 sampled residents (Resident 21) reviewed for dignity. This failure placed residents at risk for embarrassment, diminished self-worth, and a decreased quality of life.Findings included. Record Review of the facility's policy titled, Indwelling Urinary Catheters, date revised April 2018, documented, .8. Residents with catheter bags will have them covered or use of bags that provided dignity while in bed with visibility from hallway, out of their room or in community. Resident 21 was admitted to the facility on [DATE]. The Modification of Admission/Medicare - 5 day Minimum Data Set, an assessment tool, dated 01/13/2026, documented Resident 21 was moderately cognitively impaired and had an indwelling catheter. Record review of Resident…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-10 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 residents and/or resident representatives were informed and provided consent before administering psychotropic medications (a medication capable of affecting the mind, emotions, and/or behaviors) for 2 of 6 sampled residents (Residents 5 & 4) reviewed for unnecessary medications and/or medication consent. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications, and a diminished quality of life.Findings included. Record Review of the facility's policy titled, Behavior Management/Psychotropic Medication Overview, date revised July 2025, documented, .10. Resident or representative must be fully informed, and consent will be obtained when psychotropic medications are initiated or dosage increased. Resident 5 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 03/19/2026, showed Resident 5…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-10 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent 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 interview and record review, the facility failed to monitor for adverse side effects (ASE) of antianxiety medication (a class of drugs used to treat anxiety [a mental health condition that causes fear, a constant feeling of being overwhelmed, and excessive worry about everyday things]) and/or failed to complete an AIMS (Abnormal Involuntary Movement Scale) test (a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications [a class of drugs primarily used to treat mental health conditions such as hallucinations and delusions]) and/or failed to place a stop date order of 14 days for PRN (as needed) psychotropic medication (a medication capable of affecting the mind, emotions, and/or behaviors), and failed to ensure resident specific target behaviors were monitored prior to administering antianxiety medication for 3 of 6 sampled residents (Residents 3, 4, and 25) reviewed for unnecessary medications. This failure…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-10 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    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 the Pre-admission Screening and Resident Review (PASRR) Level I, a screening tool used to identify mental health needs, was requested upon a significant change of condition for 1 of 6 residents (Resident 7) reviewed for PASRR. This failure placed the residents at risk of unidentified mental health needs, and a diminished quality of life.Findings included . Record Review of the facility's policy titled, Pre-admission Screening and Resident Review WA (PASRR), revised June/2024, documented, .6. The PASRR will be reviewed and updated as indicated with significant changes in resident's physical or mental condition. The state mental health authority will be notified of the changes affecting the resident's physical or mental condition. Resident 7 was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS, an assessment tool), dated 01/28/2026, showed Resident 7 was moderately cognitively impaired and was exhibiting signs of…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 fully address lab results as reported by laboratory services for 1 of 1 resident (Resident 31) reviewed for death. This failure placed residents at risk for adverse side effects and a diminished quality of life. Findings included .Resident 31 was admitted to the facility on [DATE] and passed away on 03/08/2026. The admission /Medicare - 5 Day minimum data set, an assessment tool, dated 02/27/2026, documented Resident 31 was severely cognitively impaired. Record review of Resident 31's electronic health record showed a physician's order, dated 03/05/2026, for CBC (complete blood count) with Platelets, BMP (Basic metabolic panel, a blood test measuring kidney health, electrolyte balance; essential minerals including sodium, potassium, calcium, magnesium, chloride, and phosphate, fluid status, and blood sugar levels).Record review of Resident 31's laboratory results, dated 03/07/2026, indicated, Mild Hemolysis [blood sample destruction] Present; Some…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-10 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 adequately monitor residents' heart rate (HR) for 1 of 5 residents (Resident 3) reviewed for unnecessary medications. This failure placed residents at risk for adverse side effects and a diminished quality of life. Findings included.Resident 3 was admitted to the facility on [DATE]. The 5-day Minimum Data Set, an assessment tool, dated 03/13/2026, indicated Resident 3 was alert and oriented and had a diagnosis of chronic atrial fibrillation (irregular heart rhythms that do not revert to normal rhythm on their own).Record review of Resident 3's electronic health record (EHR) showed a Physician's order, dated 03/09/2026, for Digoxin (medication used to manage irregular heart rhythms) Oral Tablet 125 MCG (micrograms) to give 1 tablet orally in the morning for atrial fibrillation.Record review of Resident 3's EHR showed Resident 3's HR was 58 bpm (beats per minute) on 03/13/2026, 56 bpm on 03/20/2026, 59 bpm on 03/23/2026, 57 bpm on 03/27/2026 and 51 bpm…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 observations, interviews and record review, the facility failed to ensure that pressure ulcers were appropriately identified, and physician orders were obtained for 1 of 4 (Resident 1) residents reviewed for quality of care. This failure resulted in Resident 1 developing pressure wounds and not receiving appropriate medical interventions.Findings included. Review of the facility's Pressure Ulcer Prevention Guidelines, dated March 2014, documented, It is the policy of this facility to implement care and services to prevent residents from developing pressure ulcers. 1. Pressure ulcer prevention interventions include 4 major approaches: a. Minimizing pressure.b. Managing moisture. c. Prevention of friction and shear [skin tearing or damage].d. Maintaining adequate nutrition and hydration.Review of the facility's policy Skin at Risk program, dated April 2018, documented, Procedure 4. An appropriate treatment order will be obtained from the resident's physician and implemented when a wound is identified.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-09 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 observations, interviews and record review, the facility failed to ensure that allegations of abuse were reported timely for 1 of 2 [Resident 1] sampled residents reviewed for abuse/neglect. This failure placed residents at risk for potential verbal and physical abuse, and a diminished quality of life. Findings included. Review of the facility's Abuse/Neglect/Misappropriation/Exploitation policy dated 10/2022, documented that Individual mandatory reporters must immediately report to the Abuse Hotline when there is reasonable cause to believe an incident is abuse, neglect or exploitation. Resident 1 was admitted to the facility on [DATE] for rehabilitation following a hospitalization. The Quarterly Minimum Data Set, an assessment tool, dated 07/08/2025, indicated that Resident 1 was mildly cognitively impaired.Review of Resident 1's Electronic Health Record (EHR) dated 07/25/2025, at 2:33 AM, showed Staff D, Licensed Practical Nurse (LPN) documented in the progress notes Resident 2 was raising her voice,…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-05-23 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    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 appropriate Personal Protective Equipment (PPE) use was implemented during linen sorting and washing machine cleaning in 1 of 1 facility laundry areas, failed to ensure PPE was used during personal care for 1 of 1 sampled resident (Resident 14), failed to ensure safe hand hygiene practices were implemented during dressing changes for 2 of 3 sampled residents (Residents 12 and 124), failed to develop a complete Water Management Program to reduce the risk of Legionella (a family of micro-organisms which are naturally found in water bodies) growth and spread in the facility, and failed to create an Infection Prevention and Control Program based on a facility and community-based infection control (IC) risk assessment. These failures placed residents at risk of potential contaminants being passed from staff to residents, worsening wound infections, and developing Legionnaires disease (a severe form of pneumonia, a lung infection,…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Ecited before2025-05-23 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to identify and report potential allegations of abuse and/or neglect to the State Survey Agency as required for 2 of 3 sampled residents (Resident 5 and X). This failure placed residents at risk for further abuse and/or neglect and a diminished quality of life. Findings included . Review of the facility's policy entitled Abuse/Neglect/Misappropriation/Exploitation, revised 10/2022, showed the facility would ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials [including to the State Survey Agency and adult protective services where state law provides…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-23 · tag F0699 — pattern
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to develop a trauma trigger (a psychological stimulus that prompts recall of a previous traumatic event) assessment for 2 of 2 sampled residents (Residents 17 and 12) reviewed trauma informed care. This failure placed residents at risk for unidentified trauma triggers, behaviors, re-traumatization and a diminished quality of life. Findings included . <Resident 17> Record review of Resident 17's admission record, undated, showed she was admitted to the facility on [DATE]. The facility matrix (documented used to identify pertinent care categories), undated, showed Resident 17 had a diagnosis of Post Traumatic Stress Disorder/Trauma (PTSD). Resident 17's care plan, dated 03/16/2025, showed a focus problem, Potential alteration in psychosocial well-being related to survivor of traumatic event . The care plan had a goal that, Triggers of traumatic event will be minimized . Record review of Resident 17's Psychosocial History and Discharge Plan, effective…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-23 · tag F0761 — failed to label and store drugs safely — pattern
    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.
    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 observations and interviews, the facility failed to ensure treatment carts were locked for 1 of 1 treatment carts (Treatment Cart 1), and failed to ensure medication dosages were accurately labeled for 1 of 6 sampled residents (Resident 14) reviewed for medication storage. This failure placed residents at risk for having access to treatment supplies not prescribed and receiving incorrect doses of medications. Findings included . <Unlocked Treatment Cart> On 05/19/2025 at 9:25 AM and 9:57 AM, Treatment Cart 1 was observed to be unlocked. The treatment cart contained a total of 18 containers of antifungal powder and creams (treatment for fungal skin problems), 2 tubes of hydrocortisone 1 percent (%) cream (treats skin problems), 3 tubes of lidocaine ointment 5% (treatment for skin pain), 2 tubes of zinc oxide paste (protects the skin from moisture), 3 tubes of estradiol vaginal cream 0.01% (treats vaginal dryness, and irritation), 2 containers of clobetasol propionate 0.05% (treats severe skin…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-23 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure urinary tract infection related antibiotic initiation practices were based on Center for Disease Control and Prevention (CDC) approved criteria. This failure placed residents at risk of receiving or not receiving necessary antibiotics and a diminished quality of care. Findings included . The facility's Antibiotic Stewardship Policy, revised 04/2023, did not identify what urinary tract infection qualifying symptom criteria was to be used to assist providers in determining if resident symptom presentation met criteria threshold to initiate use of an antibiotic. On 05/23/2025 at 10:14 AM, Staff B, Registered Nurse and Director of Nurses Services, said the facility created an SBAR (a structured communication tool used to facilitate clear and concise communication) tool the nurses used to report urinary tract infection related symptoms and concerns to a resident's provider. When asked what antibiotic initiating criteria the SBAR contained, Staff B stated, McGeer's criteria. Review of CFR 483.80(a)(3) showed 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-23 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 accurately assess the dental status on the Minimum Data Set (MDS) assessment for 1 of 3 sampled residents (Resident 17) reviewed for assessment accuracy. This failure placed residents at risk for unmet dental and nutritional needs and a diminished quality of life. Findings included . Record review of Resident 17's admission Record document, undated, showed she was admitted to the facility on [DATE] with diagnoses of failure to thrive, poor calorie intake and malnutrition. On 05/19/2025 at 10:33 AM, Resident 17 said her dentures were outdated. The resident was observed pointing to her front top dentures and said her two front teeth were missing. The resident said she needed to have her dentures fixed and then she might be able to eat and chew better. Record review of Resident 17's care plan, dated 03/18/2025, showed the resident had an oral hygiene performance deficit due to full upper and lower dentures. The MDS, dated [DATE], showed…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-23 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness (SMI), Intellectual Disabilities (ID), and related conditions are not inappropriately placed in nursing homes for long-term care) Level I form was completed accurately and Level II PASARR referrals were made for 2 of 5 sampled residents (Residents 8 & 9) reviewed PASARR screening. These failures placed residents at risk of not receiving specialized mental health services and a diminished quality of care. Findings included . Review of the facility's policy entitled Pre-admission Screening and Resident Review WA [PASARR], revised June 2024, showed, Level II PASRR evaluations are required for all nursing facility residents identified to have indicators of SMI/ID during the Level I screening or at any time during residency in the nursing facility, and for any resident with confirmed SMI or ID who…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-23 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 ensure person centered care plans were completed to address all aspects of care including individualized goals and approaches for eating and for assistance with turning and repositioning for 2 of 14 sampled residents (Resident 4 & 14) reviewed for care plans addressing resident needs. These failures placed residents at risk for inconsistent and/or inadequate care and treatment and diminished quality of care. Findings included . RESIDENT 4 Review of the admission Record, undated, showed Resident 4 was admitted to the facility on [DATE] with diagnoses including dysphasia (difficulty swallowing food or liquids) and cerebral vascular disease (stroke). The quarterly Minimum Data Set (MDS) assessment, dated 02/28/2025, showed the resident required a mechanically altered diet (thickened liquids). On 05/19/2025 at 11:00 AM, Resident's 4 room was observed with signs giving the following instructions to caregivers: --[Resident 4's] get up…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-23 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to implement physician's orders for a heart and a breathing medication during medication administration for 1 of 6 sampled residents (Resident 11) reviewed for services provided meet professional standards. This failure placed residents at risk for adverse outcomes for a heart rate below 60, mouth irritation, and a diminished quality of care. Findings included . <Heart Medication> On 05/22/2025 at 8:06 AM, during a medication administration observation, Resident 11's physician's order showed to administer a heart medication, give one tablet orally in the morning for heart failure. Check apical pulse (pulse at the heart) prior to administering medication. If below 60 hold medication and call the physician. Staff F, Registered Nurse, said she would hold the medication because the resident's pulse was 45 beats per minute this morning. Record review of Resident 11's April 2025 Medication Administration Record (MAR) showed on 16 out of the 30 days the pulse was below 60 and one day was documented X. Record review of…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-23 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 provide restorative nursing services including a restorative stretching program for 1 of 2 sampled residents (Resident 10) reviewed for maintaining activities of daily living. This failure placed residents at risk for avoidable decline in function and a diminished quality of life. Findings included . The admission record, undated, showed Resident 10 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment, dated 03/11/2025, showed the resident was cognitively impaired and required substantial to maximum assistance with bed mobility and transfers. A Restorative Program Referral Form, dated 05/12/2025, documented, Stretching program-while in chair, straighten left lower leg (LLE) extremity as far as tolerable. Hold for 45 seconds-1 minute. Repeat X5 [five times] or to a maximum tolerance. On 05/22/2025 at 11:39 AM, Staff B, Director of Nursing Services, said one resident in the facility, Resident 10, was on a restorative…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-23 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 provide toileting, repositioning, and pressure relieving devices for 1 of 4 sampled residents (Resident 14) reviewed for activities of daily living for dependent residents. This failure placed residents at risk for skin impairment including developing a pressure injury (PI) and a diminished quality of life. Findings included . Per the admission Record, undated, Resident 14 admitted to the facility on [DATE], with diagnoses including a stroke (a sudden interruption of blood flow to the brain). Review of Resident 14's Braden Scale (an assessment tool that measures risk for pressure injury), dated 04/25/2025, scored the resident as 14, moderate risk for PI development. The Braden Scale noted the resident had redness in the peri area and buttocks and required staff assistance with all locomotion and bed mobility. Resident 14's Skin Integrity Care Plan, dated 04/25/2025, included a goal of, The resident will not have avoidable skin impairment…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-23 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 provide an ongoing activity program of meaningful engagement to meet individual resident needs for 1 of 2 sampled residents (Resident 14) reviewed for activities. This failure placed residents at risk of boredom and a diminished quality of life. Findings included . Resident 14 was admitted to the facility on [DATE] with diagnoses including stroke (a sudden interruption of blood flow to the brain), muscle weakness affecting one side of the body and/or paralysis of one side of the body, aphasia (neurological condition that affects ability to communicate) and other reduced mobility. Review of Resident 14's Minimum Data Set assessment, dated 04/29/2025, showed the resident's family or significant other was interviewed regarding Resident 14's activity preferences, and indicated the resident liked listening to music and it was not important for the resident to keep up with the news. On 05/19/2025 at 9:12 AM, 11:44 AM, 1:22 PM and 3:14 PM,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 provide pressure reducing measures and repositioning to prevent and/or contribute to the development of a pressure injury for 1 of 3 sampled residents (Resident 14) reviewed for pressure injury (areas of damaged skin and tissue caused by sustained pressure). This failure placed residents at risk for developing pressure ulcers, pain and a diminished quality of life. Findings included . REVISED NATIONAL PRESSURE ULCER ADVISORY PANEL PRESSURE INJURY STAGING SYSTEM -Stage 2 Pressure Injury (PI) - Partial thickness with exposed middle layer of skin. Resident 14 was admitted to the facility on [DATE] with diagnoses including diabetes (abnormal processing of sugar), a stroke (a sudden interruption of blood flow to the brain) and decreased mobility in both arms and legs. Review of Resident 14's Braden Scale (an assessment tool that measures risk for pressure injury), dated 04/25/2025, scored the resident as 14, moderate risk for PI development.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    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 secure electronic smoking (involves using battery-powered devices called e-cigarettes or vapes) materials for 1 of 1 sampled resident (Resident 8); and failed to implement a system for securing and storing potentially toxic chemicals in 1 of 1 shower room (shower room [ROOM NUMBER]) reviewed for accident hazards. These failures placed residents at risk for accidents, injury and a diminished quality of life. Findings included . ELECTRONIC SMOKING Review of the facility's policy entitled Smoking/E-Cigarette Safety Program, revised 04/2024, showed smoking supplies were to be stored at the nurses station. The resident's admission Record, undated, showed the resident was admitted to the facility on [DATE] with diagnoses including a stroke (a medical condition that occurs when blood flow to the brain is interrupted or reduced, causing brain cells to die) which resulted in limited movement in his right arm and leg. A review of Resident 8'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-23 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 adequate indication for medication was provided for 1 of 5 sampled residents (Resident 223) reviewed for unnecessary medications. This failure placed residents at risk for adverse side effects and a diminished quality of care. Findings included . Per the admission Record, undated, Resident 223 was admitted to the facility on [DATE] and showed she was alert, oriented and able to make needs known. A physician's order, dated 05/16/2025, showed upon admission Resident 223 was prescribed Diclofenac (pain medication) and Eliquis (blood thinner used to prevent and treat blood clots). The facility's Potential Drug Interaction report, dated 05/16/2025, from the facility's long-term care pharmacy, documented receiving both Diclofenac and Eliquis may be Concurrent therapy and approach use with caution. A nursing progress note, dated 05/17/2025, documented Resident 223 had Concerns about medication interactions between Eliquis and Diclofenac. Refused to…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-03-08 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to provide at least eight hours of Registered Nurse (RN) supervision for 9 of 30 days reviewed for RN coverage. This failure placed residents at risk for not receiving needed care and supervision of care. Findings included . The facility's Staffing Pattern Form, dated 02/03/2024 through 03/03/2024, documented there was no RN coverage for 9 of 30 days reviewed (02/03/2024, 02/10/2024, 02/13/2024, 02/17/2024, 02/21/2024, 02/22/2024, 02/24/2024, 02/27/2024, and 03/02/2024). On 03/07/2024 at 9:24 AM, Staff B, Director of Nursing Services and Registered Nurse, said the facility was actively recruiting, and hired two RN staff. Staff B said the facility had a low hiring pool. Staff B said the facility had been short on RN coverage. Reference WAC 388-97-1080 (3) .

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-08 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 equipment was provided to prevent further avoidable reduction of range of motion (ROM) and mobility for 1 of 2 sampled residents (1) reviewed for ROM/mobility. This failure placed residents at risk for increased contractures and decrease quality of life. Findings included . Resident 1 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) affecting the right side and contracture (a condition of shortening and hardening of muscles and tendons often leading to deformity and rigidity of joints) unspecified hand. The Minimum Data Set, a comprehensive assessment tool, dated 01/07/2024, documented Resident 1 was dependent on staff assistance with bed mobility, transfers, dressing, toilet use and hygiene. Record review of Resident 1's Restorative Program Referral Form, dated 02/14/2023, documented, Gentle Passive Range of Motion (PROM) to Right Upper…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-01 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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' medical information was maintained in a manner to ensure privacy and confidentiality when staff failed to secure the electronic medical records (EMR) for 1 of 7 sampled residents (Resident 1) reviewed for privacy and confidentiality. This failure placed residents at risk of having their medical information not kept confidential and a diminished quality of life. Findings included . Resident 1 was admitted to the facility 04/14/2023. On 08/01/2023 at 2:30 PM, a facility laptop was observed on top, of the only medication cart, with the screen on and displaying Resident 1's Medication Administration Record with his name, diagnoses, a photo of him and several medications ordered for the resident visible. Nursing staff was not observed near the cart or in the hallway. At 2:34 PM, Staff C, Licensed Practical Nurse and Cart/Charge Nurse, was observed walking towards the cart. When beginning to ask about the open record, Staff C quickly hit two keys on the keyboard which displayed a privacy screen 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2024-11-27 · tag F0609 — failed to report abuse allegations — widespread
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 the State Agency was notified and a entry on their Accident/Incident Log was completed when a tree uprooted and fell on the building causing a puncture in the apex of the roof. This failure placed residents at risk for an unsafe living environment and diminished quality of life. Findings included . On 11/19/2024, at 11:10 AM, a tarp was observed from the back parting lot of the facility covering part of the roof and the outside wall on the right side of the facility. At 11:14 AM, from the entrance to the facility, the far right wall of the dining room, adjacent to the driveway leading to the back parking lot, was observed to be covered in protective plastic tarping with signs with the word Danger on them. At 11:15 AM, Staff C, Activities Assistant, said a tree had fallen on the roof a few weeks ago and it was in the process of being repaired. At 1:15 PM, when asked when the tree fell on the roof, Staff D, Licensed Practical Nurse and Resident Care Manager, referred to a group text he received on his…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$8,278 in federal fines across 1 penalty.

  • $8,278 — penalty dated 2025-01-13

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

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 →

RatingThis homeChain avg
Overall 5 of 53.9+1.1 vs chain
Health inspection 4 of 53.7+0.3 vs chain
Staffing 3 of 54.0-1.0 vs chain
Quality measures 5 of 53.6+1.4 vs chain
The other 26 homes this chain runs (chain average 3.9★, per CMS)
1 of 5Pilot Butte Rehabilitation CenterBend, OR 1 of 5Puyallup Post AcutePuyallup, WA 2 of 5Park Rose Care CenterTacoma, WA 2 of 5Regency AlbanyAlbany, OR 2 of 5Regency Coupeville Rehab And Nursing CenterCoupeville, WA 3 of 5Kauai Care CenterWaimea, HI 3 of 5Laurel Hill Nursing CenterGrants Pass, OR 3 of 5Regency Hermiston Nursing & Rehab CenterHermiston, OR 3 of 5Sharon Care CenterCentralia, WA 3 of 5View Ridge Care CenterEverett, WA 4 of 5Arlington Health And RehabilitationArlington, WA 4 of 5Regency Care Center At MonroeMonroe, WA 4 of 5Regency FlorenceFlorence, OR 5 of 5Good Samaritan Health Care CtrYakima, WA 5 of 5Mt Baker Care CenterBellingham, WA 5 of 5Regency At NorthpointeSpokane, WA 5 of 5Regency At The ParkCollege Place, WA 5 of 5Regency Canyon Lakes Rehab And Nursing CenterKennewick, WA 5 of 5Regency Care Of Central OregonBend, OR 5 of 5Regency Care Of Rogue ValleyGrants Pass, OR 5 of 5Regency Gresham Nursing & Rehabilitation CenterGresham, OR 5 of 5Regency Harmony House Rehab & NursingBrewster, WA 5 of 5Regency OmakOmak, WA 5 of 5Regency Prineville Rehabilitation and Nursing CentPrineville, OR 5 of 5Regency Redmond Rehabilitation And Nursing CenterRedmond, OR 5 of 5Regency Wenatchee Rehabiliation & Nursing CenterWenatchee, WA

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 / managerTypeRoleShareSince
BD FACILITIES LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/01/2009
BEDDOE, MARVINIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL99%since 04/01/2010
REGENCY PACIFIC MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2010

CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners 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.

$3.5M
Net patient revenuemost recent cost report
-13.5%
Operating marginrevenue minus expenses
$193K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 50%Medicare 25%Other / private 25%

This home reported $193K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$487per resident / day
operating cost
$14,805per month
≈ monthly operating cost
$429per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Washington
$13,155/mo
Nursing home (semi-private)
$15,969/mo
Nursing home (private)
$7,600/mo
Assisted living

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 505515. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-10, 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.

What to do next