Cycle 1
Health 2025-04-01 · Fire 2025-04-01
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Olympia, WA
Olympia Transitional Care And Rehabilitation
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
430 Lilly Road Northeast, Olympia, WA
(360) 491-9700
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
113
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1976-07-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.86
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.53
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.93
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
4.40
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,815
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.55
Composite VBP score used to determine payment impact.
Payment multiplier
1.0011
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.76
Baseline 16.98% · Performance 17.83% · Measure score 7.76 · Achievement 7.76 · Improvement 0
Healthcare-associated infections
3.14
Baseline 6.21% · Performance 6.89% · Measure score 3.14 · Achievement 3.14 · Improvement 0
Total nurse turnover
5.31
Performance 41.98% · Measure score 5.31 · Achievement 5.31 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.80
Baseline 3.98 hours · Performance 3.88 hours · Measure score 2.80 · Achievement 2.80 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.47% |
10.72%
2.2 pts better
|
No Different than the National Rate · Eligible stays 264 · Observed rate 6.06% · Lower 95% interval 6.04% |
| Discharge to community | 60.84% |
50.57%
10.3 pts better
|
Better than the National Rate · Eligible stays 308 · Observed rate 54.22% · Lower 95% interval 55.85% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.46% |
95.27%
4.2 pts better
|
Numerator 183 · Denominator 184 |
| Falls with major injury | 0.54% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 184 |
| Discharge self-care score | 75.35% |
53.69%
21.7 pts better
|
Numerator 107 · Denominator 142 |
| Discharge mobility score | 72.54% |
50.94%
21.6 pts better
|
Numerator 103 · Denominator 142 |
| Pressure ulcers or injuries, new or worsened | 6.52% |
2.29%
4.2 pts worse
|
Numerator 12 · Denominator 184 · Adjusted rate 5.11% |
| Healthcare-associated infections requiring hospitalization | 6.89% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 203 · Observed rate 6.9% · Lower 95% interval 4.92% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 142 |
| Staff flu vaccination coverage | 42.42% |
42%
0.4 pts better
|
Numerator 70 · Denominator 165 |
| Discharge function score | 76.76% |
56.45%
20.3 pts better
|
Numerator 109 · Denominator 142 |
| Transfer of health information to provider | 88% |
95.95%
8 pts worse
|
Numerator 44 · Denominator 50 |
| Transfer of health information to patient | 97.17% |
96.28%
0.9 pts better
|
Numerator 103 · Denominator 106 |
| Resident COVID-19 vaccinations up to date | 36.17% |
25.2%
11 pts better
|
Numerator 34 · Denominator 94 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.4
0.2 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.6 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.4 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.0%
4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.8% |
93.8%
2 pts better
|
95.5%
0.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
2.6%
1 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.1% · Q3 3.2% · Q4 3.4% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.7% |
16.3%
5.6 pts better
|
11.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 5.3% · Q3 29.6% · Q4 2.3% · 4Q avg 10.7% |
| Percentage of long-stay residents who lose too much weight | 10.3% |
5.8%
4.5 pts worse
|
5.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 11.7% · Q3 6.9% · Q4 7.8% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.8% |
12.1%
0.3 pts better
|
19.6%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 11.7% · Q3 11.5% · Q4 15.4% · 4Q avg 11.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.5% |
15.9%
10.6 pts worse
|
16.7%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 29.4% · Q3 29.4% · Q4 17.5% · 4Q avg 26.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.5% |
20.0%
7.5 pts better
|
16.3%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 8.7% · Q4 21.0% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.3% |
15.8%
2.5 pts worse
|
14.9%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 12.7% · Q3 24.5% · Q4 22.9% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.2%
0.3 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.7%
0.4 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 7.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.7% |
23.5%
5.8 pts better
|
19.8%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 12.8% · Q3 21.1% · Q4 16.7% · 4Q avg 17.7% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
4.7%
0.4 pts worse
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 3.2% · Q3 7.4% · Q4 1.5% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
87.7%
10.6 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 98.5% · Q3 98.4% · Q4 98.5% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
13.2%
0.6 pts better
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 12.8% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.4%
0.7 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.2% |
82.0%
8.2 pts better
|
79.7%
10.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.6% |
19.9%
7.3 pts better
|
23.9%
11.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 12.2% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-26 · Fire 2024-01-26
17 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2023-02-24 · Fire 2023-02-24
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-01
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-04-01
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-04-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-04-01
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-04-01
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-04-01
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-18
F · Potential for more than minimal harm
2024-01-26
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-02-26
F · Potential for more than minimal harm
2024-01-26
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-02-26
F · Potential for more than minimal harm
2024-01-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-26
F · Potential for more than minimal harm
2024-01-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-26
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-26
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-26
F · Potential for more than minimal harm
2023-02-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-02-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-02-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-02-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-02-24
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-02-24
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-02-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-30
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2026-02-27
E · Potential for more than minimal harm
2025-04-01
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-01
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-01
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-01
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-01
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-01
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-05-09
D · Potential for more than minimal harm
2024-10-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-08-27
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-09-17
G · Actual harm
2024-05-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-26
E · Potential for more than minimal harm
2024-05-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-03-25
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-04-13
E · Potential for more than minimal harm
2024-01-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-28
E · Potential for more than minimal harm
2024-01-26
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-02-28
E · Potential for more than minimal harm
2024-01-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-28
E · Potential for more than minimal harm
2024-01-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-28
E · Potential for more than minimal harm
2024-01-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-01-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-01-26
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-01-26
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-01-26
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-01-26
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-01-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-01-26
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-02-28
D · Potential for more than minimal harm
2023-02-24
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-02-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-24
Penalties and ownership
What sits behind the stars
Ownership
Pennant Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Jenkins, Tracy
Corporate Officer · Individual
Smith, Joel
Operational/Managerial Control · Individual
Smith, Joel
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Woodard Creek Health & Rehabilitation
Olympia, WA
1-star overall rating with 1-star inspections with 34 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Panorama City Conv & Rehab Ctr
Lacey, WA
5-star overall rating with 4-star inspections with $11,190 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Regency Olympia Rehabilitation And Nursing Center
Olympia, WA
4-star overall rating with 3-star inspections with $8,278 in total fines with 17 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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