Cycle 1
Health 2025-03-04 · Fire 2025-03-04
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
College Place, WA
Regency At The Park
3-star overall rating with 3-star inspections with $148,838 in total fines with 10 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
1440 Se Garrison Village Way, College Place, WA
(509) 529-4480
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
106
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Regency Pacific Management
Operator or chain grouping
Approved since
1974-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.09
Registered nurse staffing
LPN hours / resident day
0.56
Licensed practical nurse staffing
Aide hours / resident day
2.53
Nurse aide staffing
Weekend hours
3.50
Weekend nurse staffing
RN turnover
47%
Annual RN turnover
Total nurse turnover
51%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.4
0.7 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.0%
4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
93.8%
2.8 pts better
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.4% |
2.6%
5.8 pts worse
|
3.3%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 9.6% |
16.3%
6.7 pts better
|
11.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.5% |
5.8%
0.3 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.5% |
12.1%
5.4 pts worse
|
19.6%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 25.5% |
15.9%
9.6 pts worse
|
16.7%
8.8 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 | 16.7% |
20.0%
3.3 pts better
|
16.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.6% |
15.8%
5.8 pts worse
|
14.9%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.2%
0.1 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 7.7% |
1.7%
6 pts worse
|
1.7%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.7% |
23.5%
0.2 pts worse
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
4.7%
1.9 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.3% |
87.7%
3.4 pts worse
|
81.7%
2.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.2% |
13.2%
8 pts worse
|
12.0%
9.2 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.4%
1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.2% |
82.0%
3.2 pts better
|
79.7%
5.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| 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 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-18 · Fire 2024-01-18
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-02-16 · Fire 2023-02-16
10 health deficiencies
Top issue: Infection Control (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-04
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-03-04
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-03-04
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-03-04
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 2025-03-25
F · Potential for more than minimal harm
2025-03-04
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 2025-03-25
F · Potential for more than minimal harm
2025-03-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-03-04
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-03-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-03-04
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-03-04
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-03-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-03-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-03-04
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-03-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-03-04
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-03-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-25
F · Potential for more than minimal harm
2024-01-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-02-13
F · Potential for more than minimal harm
2024-01-18
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-02-13
F · Potential for more than minimal harm
2024-01-18
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-02-13
F · Potential for more than minimal harm
2024-01-18
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 2024-02-13
F · Potential for more than minimal harm
2024-01-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-13
F · Potential for more than minimal harm
2024-01-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-07
F · Potential for more than minimal harm
2024-01-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-13
F · Potential for more than minimal harm
2024-01-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-13
E · Potential for more than minimal harm
2024-01-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-13
D · Potential for more than minimal harm
2024-01-18
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 2024-02-13
D · Potential for more than minimal harm
2024-01-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-13
D · Potential for more than minimal harm
2024-01-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-13
D · Potential for more than minimal harm
2024-01-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-13
D · Potential for more than minimal harm
2024-01-18
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-02-13
F · Potential for more than minimal harm
2023-02-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-03-07
F · Potential for more than minimal harm
2023-02-16
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 2023-03-07
F · Potential for more than minimal harm
2023-02-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-07
D · Potential for more than minimal harm
2023-02-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-07
Inspection history
Recent health citations
G · Actual harm
2025-03-04
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 2025-04-22
E · Potential for more than minimal harm
2025-03-04
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-04-22
E · Potential for more than minimal harm
2025-03-04
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 2025-04-22
D · Potential for more than minimal harm
2025-03-04
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 2025-04-22
D · Potential for more than minimal harm
2025-03-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-04
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 2025-04-22
D · Potential for more than minimal harm
2025-03-04
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-04
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-04
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 2025-04-22
D · Potential for more than minimal harm
2025-03-04
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-04-22
E · Potential for more than minimal harm
2024-05-22
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-06-26
J · Immediate jeopardy
2024-01-18
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 2024-02-26
G · Actual harm
2024-01-18
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2024-02-26
G · Actual harm
2024-01-18
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-02-26
E · Potential for more than minimal harm
2024-01-18
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-18
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 2024-02-26
D · Potential for more than minimal harm
2024-01-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-18
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-18
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 2024-02-26
D · Potential for more than minimal harm
2024-01-18
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 2024-02-26
D · Potential for more than minimal harm
2024-01-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-18
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 2024-02-26
D · Potential for more than minimal harm
2024-01-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-18
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-16
D · Potential for more than minimal harm
2023-11-06
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-02-16
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 2023-03-16
E · Potential for more than minimal harm
2023-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-16
E · Potential for more than minimal harm
2023-02-16
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-16
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-16
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-16
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 2023-03-16
D · Potential for more than minimal harm
2023-02-16
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 2023-03-16
Penalties and ownership
What sits behind the stars
$97,139
2025-03-04
Fine
Fine · fine $97,139
Fine
$51,699
2024-01-03
Fine
Fine · fine $51,699
Fine
$0
2024-01-03
Payment Denial
Payment Denial · denial start 2024-03-04 · 4 days
4 day denial
Ownership
Beddoe, Marvin
5% Or Greater Direct Ownership Interest · Individual
Beddoe, Marvin
Operational/Managerial Control · Individual
Hughes, Steven
Operational/Managerial Control · Individual
Jenkins, Christopher
Operational/Managerial Control · Individual
Rapp, Andrew
Operational/Managerial Control · Individual
Regency Pacific Management LLC
Operational/Managerial Control · Organization
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