Puyallup, WA

Puyallup Nursing and Rehabilitation Center

1-star overall rating with 2-star inspections with $7,443 in total fines with 16 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle

516 23rd Ave Se, Puyallup, WA

(253) 845-6631

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Regency Pacific Management

Operator or chain grouping

Approved since

1971-08-31

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

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

0.65

Registered nurse staffing · state 0.88 · national 0.68

LPN hours / resident day

0.44

Licensed practical nurse staffing · state 0.81 · national 0.87

Aide hours / resident day

1.51

Nurse aide staffing · state 2.69 · national 2.35

Total nurse hours

2.60

All reported nurse hours · state 4.39 · national 3.89

Licensed hours

1.09

RN + LPN hours · state 1.70 · national 1.54

Weekend hours

2.30

Weekend nurse staffing · state 3.79 · national 3.43

Weekend RN hours

0.47

Weekend registered nurse coverage · state 0.63 · national 0.47

Physical therapist

0.00

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.56

CMS adjusted RN staffing hours

Adjusted total hours

2.21

CMS adjusted total nurse staffing hours

Case-mix index

1.61

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

Annual nurse turnover

SNF VBP

Value-based purchasing

Program rank

4,530

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

Performance score

39.56

Composite VBP score used to determine payment impact.

Payment multiplier

0.9925

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.15

Baseline 22.22% · Performance 19.80% · Measure score 4.15 · Achievement 3.51 · Improvement 4.15

Healthcare-associated infections

1.67

Baseline 6.12% · Performance 7.33% · Measure score 1.67 · Achievement 1.67 · Improvement 0

Total nurse turnover

5.57

Baseline 36.92% · Performance 40.91% · Measure score 5.57 · Achievement 5.57 · Improvement 0

Adjusted total nurse staffing

4.43

Baseline 4.24 hours · Performance 4.34 hours · Measure score 4.43 · Achievement 4.43 · Improvement 0.13

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.55%	10.72% 0.2 pts better	No Different than the National Rate · Eligible stays 283 · Observed rate 10.6% · Lower 95% interval 8.09%
Discharge to community	59.09%	50.57% 8.5 pts better	Better than the National Rate · Eligible stays 305 · Observed rate 51.8% · Lower 95% interval 52.7%
Medicare spending per beneficiary	0.85	1.02 0.2 pts better
Drug regimen review with follow-up	97.08%	95.27% 1.8 pts better	Numerator 166 · Denominator 171
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 171
Discharge self-care score	48.94%	53.69% 4.8 pts worse	Numerator 69 · Denominator 141
Discharge mobility score	47.52%	50.94% 3.4 pts worse	Numerator 67 · Denominator 141
Pressure ulcers or injuries, new or worsened	1.17%	2.29% 1.1 pts better	Numerator 2 · Denominator 171 · Adjusted rate 1.26%
Healthcare-associated infections requiring hospitalization	7.34%	7.12% 0.2 pts worse	No Different than the National Rate · Eligible stays 142 · Observed rate 7.75% · Lower 95% interval 4.82%
Staff COVID-19 vaccination coverage	14.29%	8.2% 6.1 pts better	Numerator 19 · Denominator 133
Staff flu vaccination coverage	31.3%	42% 10.7 pts worse	Numerator 41 · Denominator 131
Discharge function score	50.35%	56.45% 6.1 pts worse	Numerator 71 · Denominator 141
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 31 · Denominator 31
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 130 · Denominator 130
Resident COVID-19 vaccinations up to date	26.21%	25.2% 1 pts better	Numerator 27 · Denominator 103

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.9%	96.0% 2.9 pts better	93.4% 5.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 97.7% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	93.8% 6.2 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	1.7%	2.6% 0.9 pts better	3.3% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.3% · Q3 0.0% · Q4 2.2% · 4Q avg 1.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	10.9%	16.3% 5.4 pts better	11.4% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.3% · Q3 15.9% · Q4 23.8% · 4Q avg 10.9%
Percentage of long-stay residents who lose too much weight	3.6%	5.8% 2.2 pts better	5.4% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 0.0% · Q3 0.0% · Q4 9.1% · 4Q avg 3.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.0%	12.1% 2.9 pts worse	19.6% 4.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 17.5% · Q3 14.0% · Q4 11.4% · 4Q avg 15.0%
Percentage of long-stay residents who received an antipsychotic medication	26.4%	15.9% 10.5 pts worse	16.7% 9.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 21.2% · Q3 35.1% · Q4 28.2% · 4Q avg 26.4% · 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	24.5%	20.0% 4.5 pts worse	16.3% 8.2 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 24.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	18.6%	15.8% 2.8 pts worse	14.9% 3.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 12.1% · Q3 13.9% · Q4 18.4% · 4Q avg 18.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.0%	1.2% 0.2 pts better	1.0% About the same	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 0.0% · Q4 2.1% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.2%	1.7% 0.5 pts worse	1.7% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.5% · Q3 2.2% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	13.5%	23.5% 10 pts better	19.8% 6.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 12.3% · Q3 14.7% · Q4 6.1% · 4Q avg 13.5%
Percentage of long-stay residents with pressure ulcers	4.0%	4.7% 0.7 pts better	5.1% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 5.5% · Q3 3.8% · Q4 3.4% · 4Q avg 4.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	92.7%	87.7% 5 pts better	81.7% 11 pts better	Short Stay · 2024Q4-2025Q3 · Q1 92.2% · Q2 87.4% · Q3 93.8% · Q4 98.2% · 4Q avg 92.7%
Percentage of short-stay residents who had an outpatient emergency department visit	11.8%	13.2% 1.4 pts better	12.0% 0.2 pts better	Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 11.8% · Expected 11.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.9%	1.4% 0.5 pts better	1.6% 0.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 1.2% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	88.7%	82.0% 6.7 pts better	79.7% 9 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 88.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	18.0%	19.9% 1.9 pts better	23.9% 5.9 pts better	Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 17.6% · Expected 23.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-15 · Fire 2025-09-15

16 health deficiencies

Top issue: Resident Rights (7 deficiencies)

12 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 2 Health 2024-08-16 · Fire 2024-08-16

21 health deficiencies

Top issue: Resident Assessment and Care Planning (7 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-07-18 · Fire 2023-07-18

17 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-09-15

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2025-12-16

F · Potential for more than minimal harm 2025-09-15

E33 · Emergency Preparedness Deficiencies

Fire Safety

Establish methods for sharing information.

Corrected 2025-12-16

F · Potential for more than minimal harm 2025-09-15

E9 · Emergency Preparedness Deficiencies

Fire Safety

Include a process for Emergency Preparedness collaboration.

Corrected 2025-12-16

F · Potential for more than minimal harm 2025-09-15

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 2025-10-05

F · Potential for more than minimal harm 2025-09-15

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 2025-12-18

F · Potential for more than minimal harm 2025-09-15

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-10-05

F · Potential for more than minimal harm 2025-09-15

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-10-05

F · Potential for more than minimal harm 2025-09-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-10-05

F · Potential for more than minimal harm 2025-09-15

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-10-05

D · Potential for more than minimal harm 2025-09-15

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-10-05

D · Potential for more than minimal harm 2025-09-15

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-10-05

F · Potential for more than minimal harm 2025-08-22

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-08-29

F · Potential for more than minimal harm 2024-08-16

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-09-10

F · Potential for more than minimal harm 2024-08-16

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-09-10

F · Potential for more than minimal harm 2024-08-16

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-09-10

F · Potential for more than minimal harm 2024-08-16

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-09-10

F · Potential for more than minimal harm 2024-08-16

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-09-10

F · Potential for more than minimal harm 2024-08-16

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2024-09-10

F · Potential for more than minimal harm 2024-08-16

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 2024-09-10

F · Potential for more than minimal harm 2023-07-18

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-08-04

F · Potential for more than minimal harm 2023-07-18

K362 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-08-04

F · Potential for more than minimal harm 2023-07-18

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-08-04

E · Potential for more than minimal harm 2023-07-18

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-08-04

D · Potential for more than minimal harm 2023-07-18

K300 · Egress Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2023-08-04

Inspection history

Recent health citations

E · Potential for more than minimal harm 2026-01-21

F621 · Resident Rights Deficiencies

Health

Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source

Corrected 2026-03-15

E · Potential for more than minimal harm 2026-01-21

F627 · Resident Rights Deficiencies

Health

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Corrected 2026-03-15

E · Potential for more than minimal harm 2026-01-21

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2026-03-15

E · Potential for more than minimal harm 2025-09-15

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2025-10-31

E · Potential for more than minimal harm 2025-09-15

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-10-31

E · Potential for more than minimal harm 2025-09-15

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2025-10-31

E · Potential for more than minimal harm 2025-09-15

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-10-31

D · Potential for more than minimal harm 2025-09-15

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-10-31

D · Potential for more than minimal harm 2025-09-15

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-10-31

D · Potential for more than minimal harm 2025-09-15

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-10-31

D · Potential for more than minimal harm 2025-09-15

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-10-31

D · Potential for more than minimal harm 2025-09-15

F790 · Quality of Life and Care Deficiencies

Health

Provide routine and 24-hour emergency dental care for each resident.

Corrected 2025-10-31

C · Minimal harm 2025-09-15

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-10-31

E · Potential for more than minimal harm 2025-06-25

F773 · Administration Deficiencies

Health

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-06-25

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-03-19

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 2025-04-15

E · Potential for more than minimal harm 2024-08-16

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 2024-09-20

E · Potential for more than minimal harm 2024-08-16

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2024-09-20

E · Potential for more than minimal harm 2024-08-16

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2024-09-20

E · Potential for more than minimal harm 2024-08-16

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 2024-09-20

E · Potential for more than minimal harm 2024-08-16

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-09-20

E · Potential for more than minimal harm 2024-08-16

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 2024-09-20

E · Potential for more than minimal harm 2024-08-16