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
Chain footprint
27 facilities
Chain averages 4 overall / 3 health / 4 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
1.09
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.18
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.50
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.09
CMS adjusted RN staffing hours
Adjusted total hours
4.20
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,367
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9978
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.26
Baseline 19.68% · Performance 18.53% · Measure score 6.26 · Achievement 6.26 · Improvement 3.85
Healthcare-associated infections
4.08
Baseline 5.10% · Performance 6.62% · Measure score 4.08 · Achievement 4.08 · Improvement 0
Total nurse turnover
3.35
Baseline 51.95% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0.22
Adjusted total nurse staffing
4.19
Baseline 3.63 hours · Performance 4.27 hours · Measure score 4.19 · Achievement 4.19 · Improvement 2.48
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.68% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 192 · Observed rate 10.42% · Lower 95% interval 7.9% |
| Discharge to community | 51.89% |
50.57%
1.3 pts better
|
No Different than the National Rate · Eligible stays 192 · Observed rate 46.88% · Lower 95% interval 45.06% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.48% |
95.27%
3.2 pts better
|
Numerator 130 · Denominator 132 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 132 |
| Discharge self-care score | 61.82% |
53.69%
8.1 pts better
|
Numerator 68 · Denominator 110 |
| Discharge mobility score | 40.91% |
50.94%
10 pts worse
|
Numerator 45 · Denominator 110 |
| Pressure ulcers or injuries, new or worsened | 4.55% |
2.29%
2.3 pts worse
|
Numerator 6 · Denominator 132 · Adjusted rate 4.91% |
| Healthcare-associated infections requiring hospitalization | 6.62% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 136 · Observed rate 5.15% · Lower 95% interval 3.91% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 109 |
| Staff flu vaccination coverage | 25.54% |
42%
16.5 pts worse
|
Numerator 47 · Denominator 184 |
| Discharge function score | 56.36% |
56.45%
0.1 pts worse
|
Numerator 62 · Denominator 110 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 37 · Denominator 37 |
| Transfer of health information to patient | 95.31% |
96.28%
1 pts worse
|
Numerator 61 · Denominator 64 |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 11 · Denominator 66 |
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 · Adjusted 0.7 · Observed 0.8 · Expected 2.0 · Used in QM five-star |
| 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 · Adjusted 1.4 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 96.6% |
| 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 · Q1 9.8% · Q2 5.4% · Q3 8.5% · Q4 10.0% · 4Q avg 8.4% · Used in QM five-star |
| 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 · Q1 8.7% · Q2 11.5% · Q3 13.0% · Q4 5.4% · 4Q avg 9.6% |
| 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 · Q1 10.4% · Q2 3.7% · Q3 3.4% · Q4 5.4% · 4Q avg 5.5% |
| 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 · Q1 19.6% · Q2 19.6% · Q3 16.9% · Q4 14.0% · 4Q avg 17.5% |
| 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 · Q1 30.0% · Q2 23.3% · Q3 25.9% · Q4 23.4% · 4Q avg 25.5% · 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 | 16.7% |
20.0%
3.3 pts better
|
16.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 17.7% · Q4 23.9% · 4Q avg 16.7% · Used in QM five-star |
| 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 · Q1 23.9% · Q2 25.9% · Q3 7.4% · Q4 29.6% · 4Q avg 21.6% · Used in QM five-star |
| 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 · Q1 1.8% · Q2 1.3% · Q3 0.0% · Q4 1.4% · 4Q avg 1.1% · Used in QM five-star |
| 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 · Q1 10.4% · Q2 9.3% · Q3 3.4% · Q4 8.5% · 4Q avg 7.7% · Used in QM five-star |
| 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 · Q1 12.2% · Q2 32.6% · Q3 23.8% · Q4 24.4% · 4Q avg 23.7% |
| 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 · Q1 4.2% · Q2 3.9% · Q3 0.0% · Q4 3.4% · 4Q avg 2.8% · Used in QM five-star |
| 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 · Q1 78.9% · Q2 81.8% · Q3 86.1% · Q4 88.6% · 4Q avg 84.3% |
| 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 · Adjusted 21.2% · Observed 20.7% · Expected 10.9% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.4% · Used in QM five-star |
| 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 · 4Q avg 85.2% |
| 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 13.8% · Expected 19.8% · Used in QM five-star |
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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