Olympia, WA

Puget Sound Care

4-star overall rating with 4-star inspections with $8,018 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

4001 Capitol Mall Dr Southwest, Olympia, WA

(360) 754-9792

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

108

Certified beds

Average residents

95

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Caldera Care

Operator or chain grouping

Approved since

1985-09-27

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

10 facilities

Chain averages 2 overall / 2 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

0.54

Registered nurse staffing · state 0.88 · national 0.68

LPN hours / resident day

0.88

Licensed practical nurse staffing · state 0.81 · national 0.87

Aide hours / resident day

2.84

Nurse aide staffing · state 2.69 · national 2.35

Total nurse hours

4.27

All reported nurse hours · state 4.39 · national 3.89

Licensed hours

1.42

RN + LPN hours · state 1.70 · national 1.54

Weekend hours

3.45

Weekend nurse staffing · state 3.79 · national 3.43

Weekend RN hours

0.25

Weekend registered nurse coverage · state 0.63 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.54

CMS adjusted RN staffing hours

Adjusted total hours

4.21

CMS adjusted total nurse staffing hours

Case-mix index

1.39

Higher values indicate more complex resident acuity

RN turnover

42%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

55%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,779

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

31.74

Composite VBP score used to determine payment impact.

Payment multiplier

0.9867

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.07

Baseline 19.28% · Performance 20.94% · Measure score 1.07 · Achievement 1.07 · Improvement 0

Healthcare-associated infections

5.61

Baseline 6.26% · Performance 6.16% · Measure score 5.61 · Achievement 5.61 · Improvement 0.34

Total nurse turnover

2.27

Baseline 53.85% · Performance 54.39% · Measure score 2.27 · Achievement 2.27 · Improvement 0

Adjusted total nurse staffing

3.74

Baseline 3.39 hours · Performance 4.14 hours · Measure score 3.74 · Achievement 3.74 · Improvement 2.66

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.08%	10.72% 1.6 pts better	No Different than the National Rate · Eligible stays 269 · Observed rate 7.06% · Lower 95% interval 6.86%
Discharge to community	55.11%	50.57% 4.5 pts better	No Different than the National Rate · Eligible stays 294 · Observed rate 51.7% · Lower 95% interval 49.92%
Medicare spending per beneficiary	0.96	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 209 · Denominator 209
Falls with major injury	0.48%	0.77% 0.3 pts better	Numerator 1 · Denominator 209
Discharge self-care score	40.44%	53.69% 13.2 pts worse	Numerator 55 · Denominator 136
Discharge mobility score	47.06%	50.94% 3.9 pts worse	Numerator 64 · Denominator 136
Pressure ulcers or injuries, new or worsened	1.91%	2.29% 0.4 pts better	Numerator 4 · Denominator 209 · Adjusted rate 2.07%
Healthcare-associated infections requiring hospitalization	6.16%	7.12% 1 pts better	No Different than the National Rate · Eligible stays 170 · Observed rate 4.71% · Lower 95% interval 4.05%
Staff COVID-19 vaccination coverage	12.41%	8.2% 4.2 pts better	Numerator 17 · Denominator 137
Staff flu vaccination coverage	81.25%	42% 39.2 pts better	Numerator 117 · Denominator 144
Discharge function score	57.35%	56.45% 0.9 pts better	Numerator 78 · Denominator 136
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 134 · Denominator 134
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 46 · Denominator 46
Resident COVID-19 vaccinations up to date	12.5%	25.2% 12.7 pts worse	Numerator 13 · Denominator 104

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.9	1.4 0.5 pts better	1.9 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.1 · Expected 2.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.7	1.5 0.8 pts better	1.8 1.1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	94.6%	96.0% 1.4 pts worse	93.4% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 93.0% · Q3 91.5% · Q4 93.2% · 4Q avg 94.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	92.9%	93.8% 0.9 pts worse	95.5% 2.6 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 92.9%
Percentage of long-stay residents experiencing one or more falls with major injury	2.0%	2.6% 0.6 pts better	3.3% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.8% · Q3 1.4% · Q4 2.7% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	5.5%	16.3% 10.8 pts better	11.4% 5.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 5.2% · Q3 6.3% · Q4 3.0% · 4Q avg 5.5%
Percentage of long-stay residents who lose too much weight	17.2%	5.8% 11.4 pts worse	5.4% 11.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 25.8% · Q3 19.7% · Q4 12.9% · 4Q avg 17.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	7.7%	12.1% 4.4 pts better	19.6% 11.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.2% · Q3 8.7% · Q4 9.9% · 4Q avg 7.7%
Percentage of long-stay residents who received an antipsychotic medication	17.3%	15.9% 1.4 pts worse	16.7% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 19.0% · Q3 18.2% · Q4 14.8% · 4Q avg 17.3% · 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	16.9%	20.0% 3.1 pts better	16.3% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 24.7% · 4Q avg 16.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	18.7%	15.8% 2.9 pts worse	14.9% 3.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 23.8% · Q3 10.0% · Q4 13.6% · 4Q avg 18.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.3%	1.2% 0.9 pts better	1.0% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	6.3%	1.7% 4.6 pts worse	1.7% 4.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 5.8% · Q3 8.8% · Q4 4.1% · 4Q avg 6.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	28.3%	23.5% 4.8 pts worse	19.8% 8.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 33.2% · Q3 39.3% · Q4 23.4% · 4Q avg 28.3%
Percentage of long-stay residents with pressure ulcers	9.7%	4.7% 5 pts worse	5.1% 4.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 7.7% · Q3 13.0% · Q4 10.3% · 4Q avg 9.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	75.7%	87.7% 12 pts worse	81.7% 6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 88.5% · Q2 72.7% · Q3 69.8% · Q4 71.7% · 4Q avg 75.7%
Percentage of short-stay residents who had an outpatient emergency department visit	14.8%	13.2% 1.6 pts worse	12.0% 2.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 14.8% · Observed 14.3% · Expected 10.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.2%	1.4% 0.2 pts better	1.6% 0.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.0% · Q3 1.0% · Q4 1.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	67.5%	82.0% 14.5 pts worse	79.7% 12.2 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 67.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.8%	19.9% 1.9 pts worse	23.9% 2.1 pts better	Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 21.7% · Expected 23.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-07 · Fire 2024-11-07

5 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2023-10-13 · Fire 2023-10-13

7 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2022-12-08 · Fire 2022-12-08

6 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-11-07

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-12-06

F · Potential for more than minimal harm 2024-11-07

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-12-06

F · Potential for more than minimal harm 2024-11-07

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-12-06

F · Potential for more than minimal harm 2024-11-07

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2024-12-06

D · Potential for more than minimal harm 2023-10-13

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-10-27

D · Potential for more than minimal harm 2023-10-13

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-10-27

F · Potential for more than minimal harm 2022-12-08

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-02-08

E · Potential for more than minimal harm 2022-12-08

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-01-06

E · Potential for more than minimal harm 2022-12-08

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2023-01-26

E · Potential for more than minimal harm 2022-12-08

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-01-06

D · Potential for more than minimal harm 2022-12-08

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 2023-01-17

D · Potential for more than minimal harm 2022-12-08

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2023-01-06

D · Potential for more than minimal harm 2022-12-08

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-01-06

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-07-01

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 2025-08-01

F · Potential for more than minimal harm 2024-11-07

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 2024-12-16

D · Potential for more than minimal harm 2024-11-07

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 2024-12-16

D · Potential for more than minimal harm 2024-11-07

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 2024-12-16

D · Potential for more than minimal harm 2024-11-07

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-12-16

G · Actual harm 2024-03-28

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-02-12

E · Potential for more than minimal harm 2023-10-13

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 2023-11-10

E · Potential for more than minimal harm 2023-10-13

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 2023-11-10

D · Potential for more than minimal harm 2023-10-13

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-11-10

D · Potential for more than minimal harm 2023-10-13

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-11-10

D · Potential for more than minimal harm 2023-10-13

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 2023-11-10

D · Potential for more than minimal harm 2023-10-13

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 2023-11-10

D · Potential for more than minimal harm 2023-03-14

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-03-17

E · Potential for more than minimal harm 2022-12-08

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-12-30

E · Potential for more than minimal harm 2022-12-08

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 2022-12-30

D · Potential for more than minimal harm 2022-12-08

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2022-12-30

D · Potential for more than minimal harm 2022-12-08

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2022-12-30

D · Potential for more than minimal harm 2022-12-08

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2022-12-30

Penalties and ownership

What sits behind the stars

$8,018 2024-03-28

Fine

Fine · fine $8,018

Fine

Ownership

Nearby options

Other facilities in reach

#1

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

Overall: 4 / 5
Health: 3 / 5
Staffing: 4 / 5
Fines: $8,278

#2