Cycle 1
Health 2025-07-02 · Fire 2025-07-02
18 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
29 fire-safety deficiencies
Top issue: Egress (7 deficiencies)
Tacoma, WA
Park Rose Care Center
2-star overall rating with 2-star inspections with $256,703 in total fines with 18 recent health deficiencies with 29 fire-safety deficiencies in the latest cycle
3919 South 19th Street, Tacoma, WA
(253) 752-5677
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
139
Certified beds
Average residents
98
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Regency Pacific Management
Operator or chain grouping
Approved since
1976-04-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
27 facilities
Chain averages 4 overall / 3 health / 4 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
1.05
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
3.02
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
5.13
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
2.11
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
4.36
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.93
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.32
CMS adjusted total nurse staffing hours
Case-mix index
2.11
Higher values indicate more complex resident acuity
RN turnover
74%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,273
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.60
Baseline 38.75% · Performance 57.14% · Measure score 1.60 · Achievement 1.60 · Improvement 0
Adjusted total nurse staffing
1.89
Baseline 2.94 hours · Performance 3.61 hours · Measure score 1.89 · Achievement 1.89 · Improvement 1.87
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 16.67% · Lower 95% interval 7.87% |
| Discharge to community | 43.41% |
50.57%
7.2 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 25.49% · Lower 95% interval 28.82% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 87.5% |
95.27%
7.8 pts worse
|
Numerator 21 · Denominator 24 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 24 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4.17% |
2.29%
1.9 pts worse
|
Numerator 1 · Denominator 24 · Adjusted rate 3% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.53% |
8.2%
6.7 pts worse
|
Numerator 2 · Denominator 131 |
| Staff flu vaccination coverage | 12.21% |
42%
29.8 pts worse
|
Numerator 48 · Denominator 393 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.4
0.2 pts worse
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.5 · Expected 2.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.2 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
96.0%
1.2 pts better
|
93.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 98.9% · Q3 98.8% · Q4 97.8% · 4Q avg 97.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.4% |
93.8%
7.4 pts worse
|
95.5%
9.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
2.6%
0.7 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.3% · Q4 3.3% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.6% |
16.3%
9.7 pts better
|
11.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 9.1% · Q3 7.0% · Q4 3.5% · 4Q avg 6.6% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
5.8%
About the same
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 9.6% · Q3 3.6% · Q4 4.6% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.6% |
12.1%
16.5 pts worse
|
19.6%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 30.1% · Q3 30.6% · Q4 29.2% · 4Q avg 28.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.7% |
15.9%
4.8 pts worse
|
16.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 22.0% · Q3 23.7% · Q4 17.6% · 4Q avg 20.7% · 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 | 9.9% |
20.0%
10.1 pts better
|
16.3%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.8% |
15.8%
6 pts worse
|
14.9%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 29.4% · Q3 11.3% · Q4 11.1% · 4Q avg 21.8% · 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 1.0% · Q2 0.9% · Q3 0.0% · Q4 1.6% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.7%
0.3 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.6% |
23.5%
4.9 pts better
|
19.8%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 17.5% · Q3 23.6% · Q4 11.9% · 4Q avg 18.6% |
| Percentage of long-stay residents with pressure ulcers | 9.4% |
4.7%
4.7 pts worse
|
5.1%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 13.1% · Q3 7.8% · Q4 5.8% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
87.7%
6.9 pts better
|
81.7%
12.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.1% · Q2 92.2% · Q3 98.7% · Q4 100.0% · 4Q avg 94.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.1% |
13.2%
5.9 pts worse
|
12.0%
7.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 25.9% · Expected 15.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.4%
About the same
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 2.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 43.6% |
82.0%
38.4 pts worse
|
79.7%
36.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 43.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.2% |
19.9%
1.3 pts worse
|
23.9%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 33.3% · Expected 37.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-18 · Fire 2024-09-18
31 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-08-07 · Fire 2023-08-07
27 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-02
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-02
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-02
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-02
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-02
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-02
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-02
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-09-18
F · Potential for more than minimal harm
2025-07-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-09-18
F · Potential for more than minimal harm
2025-07-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-09-18
F · Potential for more than minimal harm
2025-07-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-29
F · Potential for more than minimal harm
2025-07-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-29
F · Potential for more than minimal harm
2025-07-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-09-18
F · Potential for more than minimal harm
2025-07-02
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-02
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-02
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-09-18
F · Potential for more than minimal harm
2025-07-02
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-02
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-02
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-07-02
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 2025-08-01
E · Potential for more than minimal harm
2025-07-02
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-07-02
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-07-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-07-02
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-07-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-07-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-08-01
F · Potential for more than minimal harm
2024-09-18
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-12
F · Potential for more than minimal harm
2024-09-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-09-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-12
D · Potential for more than minimal harm
2024-09-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-18
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 2024-10-17
D · Potential for more than minimal harm
2024-09-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-17
F · Potential for more than minimal harm
2023-08-07
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-07
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-07
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-07
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-07
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-09-05
E · Potential for more than minimal harm
2023-08-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-05
E · Potential for more than minimal harm
2023-08-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-05
E · Potential for more than minimal harm
2023-08-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-09-05
E · Potential for more than minimal harm
2023-08-07
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-08-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-05
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-02
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-08-12
E · Potential for more than minimal harm
2025-07-02
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-08-12
E · Potential for more than minimal harm
2025-07-02
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 2025-08-12
E · Potential for more than minimal harm
2025-07-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-12
E · Potential for more than minimal harm
2025-07-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-08-12
E · Potential for more than minimal harm
2025-07-02
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-08-12
E · Potential for more than minimal harm
2025-07-02
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 2025-08-12
D · Potential for more than minimal harm
2025-07-02
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-07-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-07-02
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-07-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-07-02
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 2025-08-12
D · Potential for more than minimal harm
2025-07-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-07-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-07-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-07-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-07-02
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 2025-08-12
C · Minimal harm
2025-07-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-08-12
D · Potential for more than minimal harm
2024-12-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-10-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-10-24
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-10-24
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-10-24
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-10-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-10
G · Actual harm
2024-09-18
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-09-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-09-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-09-18
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-09-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-09-18
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-09-18
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 2024-12-10
D · Potential for more than minimal harm
2024-09-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-09-18
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 2024-12-10
D · Potential for more than minimal harm
2024-09-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-09-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-09-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-09-18
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-09-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-09-18
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 2024-12-10
D · Potential for more than minimal harm
2024-09-18
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-12-10
C · Minimal harm
2024-09-18
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-07-11
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-06-12
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 2024-07-09
D · Potential for more than minimal harm
2024-06-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-04-29
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-04-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-04-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-29
G · Actual harm
2024-02-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-13
G · Actual harm
2024-01-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-13
D · Potential for more than minimal harm
2023-10-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-07
G · Actual harm
2023-08-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-08-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-08-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-08-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-08-07
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-08-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-08-07
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 2023-09-28
E · Potential for more than minimal harm
2023-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-08-07
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-08-07
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-07
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 2023-09-28
D · Potential for more than minimal harm
2023-08-07
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 2023-09-28
D · Potential for more than minimal harm
2023-08-07
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 2023-09-28
D · Potential for more than minimal harm
2023-08-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-07
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 2023-09-28
D · Potential for more than minimal harm
2023-08-07
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-07
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 2023-09-28
D · Potential for more than minimal harm
2023-08-07
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 2023-09-28
D · Potential for more than minimal harm
2023-08-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-07
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-07
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 2023-09-28
D · Potential for more than minimal harm
2023-08-07
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-07
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-07-20
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-07-28
Penalties and ownership
What sits behind the stars
$174,304
2024-09-18
Fine
Fine · fine $174,304
Fine
$67,511
2024-01-24
Fine
Fine · fine $67,511
Fine
$14,888
2023-08-07
Fine
Fine · fine $14,888
Fine
Ownership
Bd Facilities LLC
5% Or Greater Direct Ownership Interest · Organization
Beddoe, Marvin
5% Or Greater Indirect Ownership Interest · Individual
Amadei Gatti, Carla
Operational/Managerial Control · Individual
Andree, Terri
Operational/Managerial Control · Individual
Beddoe, Marvin
Operational/Managerial Control · Individual
Howard, Emma
Operational/Managerial Control · Individual
Rapp, Andrew
Operational/Managerial Control · Individual
Regency Pacific Management LLC
Operational/Managerial Control · Organization
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