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
Staffing
Hours and turnover
RN hours / resident day
1.05
Registered nurse staffing
LPN hours / resident day
1.06
Licensed practical nurse staffing
Aide hours / resident day
3.02
Nurse aide staffing
Weekend hours
4.36
Weekend nurse staffing
RN turnover
74%
Annual RN turnover
Total nurse turnover
60%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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