Cycle 1
Health 2025-08-12 · Fire 2025-08-12
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Puyallup, WA
Rainier Rehabilitation
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
920 12th Avenue Southeast, Puyallup, WA
(253) 841-3422
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1986-08-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.22
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
3.26
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
5.38
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
2.12
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
4.52
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
1.10
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
2.97
CMS adjusted total nurse staffing hours
Case-mix index
2.48
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,602
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.34
Composite VBP score used to determine payment impact.
Payment multiplier
1.0103
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.52
Baseline 20.40% · Performance 18.87% · Measure score 5.52 · Achievement 5.52 · Improvement 4.02
Healthcare-associated infections
7.95
Baseline 6.50% · Performance 5.46% · Measure score 7.95 · Achievement 7.95 · Improvement 6.42
Total nurse turnover
8.59
Baseline 28.04% · Performance 28.57% · Measure score 8.59 · Achievement 8.59 · Improvement 0
Adjusted total nurse staffing
0.08
Baseline 2.78 hours · Performance 2.96 hours · Measure score 0.08 · Achievement 0 · Improvement 0.08
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.19% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 7.25% · Lower 95% interval 6.39% |
| Discharge to community | 58.43% |
50.57%
7.9 pts better
|
No Different than the National Rate · Eligible stays 78 · Observed rate 42.31% · Lower 95% interval 46.83% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 63 · Denominator 63 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 63 |
| Discharge self-care score | 37.21% |
53.69%
16.5 pts worse
|
Numerator 16 · Denominator 43 |
| Discharge mobility score | 37.21% |
50.94%
13.7 pts worse
|
Numerator 16 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 1.59% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 63 · Adjusted rate 1.25% |
| Healthcare-associated infections requiring hospitalization | 5.46% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 1.89% · Lower 95% interval 3.03% |
| Staff COVID-19 vaccination coverage | 44.81% |
8.2%
36.6 pts better
|
Numerator 95 · Denominator 212 |
| Staff flu vaccination coverage | 61.76% |
42%
19.8 pts better
|
Numerator 147 · Denominator 238 |
| Discharge function score | 41.86% |
56.45%
14.6 pts worse
|
Numerator 18 · Denominator 43 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 14 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.4
0.1 pts worse
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 2.0 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.5
1.2 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.4 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
96.0%
3.7 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| 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 | 1.0% |
2.6%
1.6 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 2.1% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
16.3%
13.8 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 1.3% · Q4 6.3% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
5.8%
2.8 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 3.1% · Q3 1.2% · Q4 2.6% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.1% |
12.1%
1 pts worse
|
19.6%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 12.5% · Q3 14.6% · Q4 13.0% · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.0% |
15.9%
12.9 pts better
|
16.7%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.6% · Q3 2.7% · Q4 4.1% · 4Q avg 3.0% · 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 | 21.8% |
20.0%
1.8 pts worse
|
16.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.1% |
15.8%
5.7 pts better
|
14.9%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 10.6% · Q3 17.9% · Q4 2.9% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.2%
1.2 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.7%
1.4 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.1% |
23.5%
4.4 pts better
|
19.8%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 27.6% · Q3 19.6% · Q4 18.5% · 4Q avg 19.1% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.7%
3 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.6% · Q3 1.9% · Q4 2.5% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
87.7%
9.2 pts better
|
81.7%
15.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 100.0% · Q3 97.5% · Q4 93.8% · 4Q avg 96.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.6% |
13.2%
2.6 pts better
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 11.3% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.4%
1.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.3% |
82.0%
16.3 pts better
|
79.7%
18.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
19.9%
3.3 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 20.8% · Expected 29.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-11 · Fire 2024-07-11
0 health deficiencies
No concentrated health issue counts in this cycle.
12 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Cycle 3
Health 2023-04-21 · Fire 2023-04-21
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-12
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-09-19
F · Potential for more than minimal harm
2025-08-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-09-19
F · Potential for more than minimal harm
2025-08-12
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 2025-11-01
F · Potential for more than minimal harm
2025-08-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-19
F · Potential for more than minimal harm
2025-08-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-19
F · Potential for more than minimal harm
2025-08-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-09-19
F · Potential for more than minimal harm
2025-08-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-19
F · Potential for more than minimal harm
2025-08-12
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2025-09-19
F · Potential for more than minimal harm
2025-08-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-19
F · Potential for more than minimal harm
2025-08-12
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-08-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-11-01
D · Potential for more than minimal harm
2025-08-12
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-19
F · Potential for more than minimal harm
2024-07-11
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-07-11
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-07-11
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-07-11
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-07-11
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-07-11
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-07-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-07-11
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-07-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-07-11
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-07-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-07-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-29
F · Potential for more than minimal harm
2023-04-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-04-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-04-21
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 2023-05-12
F · Potential for more than minimal harm
2023-04-21
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-12
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-12
C · Minimal harm
2025-08-12
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-12
Penalties and ownership
What sits behind the stars
Ownership
Pennant Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Bunker, Derek
Corporate Officer · Individual
Burnam, Soon
Corporate Officer · Individual
Burton, Spencer
Corporate Director · Individual
Snapper, Suzanne
Corporate Officer · Individual
South, Clayton
Corporate Officer · Individual
Watson, Brett
Operational/Managerial Control · Individual
Watson, Brett
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Life Care Center Of Puyallup
Puyallup, WA
4-star overall rating with 4-star inspections with 16 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Puyallup Nursing and Rehabilitation Center
Puyallup, WA
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
#3
Life Care Center Of South Hill
Puyallup, WA
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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