Monroe, WA

Regency Care Center At Monroe

5-star overall rating with 4-star inspections with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

1355 West Main Street, Monroe, WA

(360) 794-4011

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

92

Certified beds

Average residents

77

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Regency Pacific Management

Operator or chain grouping

Approved since

1989-10-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.96

Registered nurse staffing

LPN hours / resident day

0.60

Licensed practical nurse staffing

Aide hours / resident day

2.45

Nurse aide staffing

Weekend hours

3.61

Weekend nurse staffing

RN turnover

26%

Annual RN turnover

Total nurse turnover

31%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 3.4
1.4
2 pts worse
1.9
1.5 pts worse
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 3.0
1.5
1.5 pts worse
1.8
1.2 pts worse
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 100.0%
93.8%
6.2 pts better
95.5%
4.5 pts better
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 5.2%
2.6%
2.6 pts worse
3.3%
1.9 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 0.0%
16.3%
16.3 pts better
11.4%
11.4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 7.1%
5.8%
1.3 pts worse
5.4%
1.7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 15.1%
12.1%
3 pts worse
19.6%
4.5 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 11.6%
15.9%
4.3 pts better
16.7%
5.1 pts better
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 24.4%
20.0%
4.4 pts worse
16.3%
8.1 pts worse
Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents with a catheter inserted and left in their bladder 3.6%
1.2%
2.4 pts worse
1.0%
2.6 pts worse
Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 18.6%
23.5%
4.9 pts better
19.8%
1.2 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 5.1%
4.7%
0.4 pts worse
5.1%
About the same
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 99.8%
87.7%
12.1 pts better
81.7%
18.1 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 14.4%
13.2%
1.2 pts worse
12.0%
2.4 pts worse
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 0.7%
1.4%
0.7 pts better
1.6%
0.9 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 95.4%
82.0%
13.4 pts better
79.7%
15.7 pts better
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 21.5%
19.9%
1.6 pts worse
23.9%
2.4 pts better
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-07 · Fire 2025-05-07

12 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

2 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 2 Health 2024-02-26 · Fire 2024-02-26

9 health deficiencies

Top issue: Nursing and Physician Services (2 deficiencies)

10 fire-safety deficiencies

Top issue: Emergency Preparedness (8 deficiencies)

Cycle 3 Health 2022-10-04 · Fire 2022-10-04

11 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-05-07

E31 · Emergency Preparedness Deficiencies

Fire Safety

Provide emergency officials' contact information.

Corrected 2025-05-26

F · Potential for more than minimal harm 2025-05-07

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2025-05-26

F · Potential for more than minimal harm 2024-02-26

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2024-03-20

F · Potential for more than minimal harm 2024-02-26

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2024-03-20

F · Potential for more than minimal harm 2024-02-26

E18 · Emergency Preparedness Deficiencies

Fire Safety

Establish procedures for tracking staff and patients during an emergency.

Corrected 2024-03-20

F · Potential for more than minimal harm 2024-02-26

E23 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for medical documentation.

Corrected 2024-03-20

F · Potential for more than minimal harm 2024-02-26

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2024-03-20

F · Potential for more than minimal harm 2024-02-26

E30 · Emergency Preparedness Deficiencies

Fire Safety

List the names and contact information of those in the facility.

Corrected 2024-03-20

F · Potential for more than minimal harm 2024-02-26

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2024-03-20

F · Potential for more than minimal harm 2024-02-26

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2024-03-20

F · Potential for more than minimal harm 2024-02-26

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-03-20

F · Potential for more than minimal harm 2024-02-26

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-04-28

F · Potential for more than minimal harm 2022-10-04

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2022-10-21

F · Potential for more than minimal harm 2022-10-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-10-14

E · Potential for more than minimal harm 2022-10-04

K915 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper power supply for life support equipment.

Corrected 2022-10-14

D · Potential for more than minimal harm 2022-10-04

K751 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of flammable curtains.

Corrected 2022-10-21

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-05-07

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2025-06-10

E · Potential for more than minimal harm 2025-05-07

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2025-06-10

E · Potential for more than minimal harm 2025-05-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-06-10

D · Potential for more than minimal harm 2025-05-07

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-06-10

D · Potential for more than minimal harm 2025-05-07

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2025-06-10

D · Potential for more than minimal harm 2025-05-07

F685 · Quality of Life and Care Deficiencies

Health

Assist a resident in gaining access to vision and hearing services.

Corrected 2025-06-10

D · Potential for more than minimal harm 2025-05-07

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-06-10

D · Potential for more than minimal harm 2025-05-07

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2025-06-10

D · Potential for more than minimal harm 2025-05-07

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2025-06-10

D · Potential for more than minimal harm 2025-05-07

F757 · Pharmacy Service Deficiencies

Health

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

Corrected 2025-06-10

D · Potential for more than minimal harm 2025-05-07

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 2025-06-10

D · Potential for more than minimal harm 2025-05-07

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 2025-06-10

F · Potential for more than minimal harm 2024-02-26

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2024-03-26

E · Potential for more than minimal harm 2024-02-26

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 2024-03-26

E · Potential for more than minimal harm 2024-02-26

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-03-26

E · Potential for more than minimal harm 2024-02-26

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 2024-03-26

E · Potential for more than minimal harm 2024-02-26

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-03-26

E · Potential for more than minimal harm 2024-02-26

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2024-03-26

D · Potential for more than minimal harm 2024-02-26

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 2024-03-26

D · Potential for more than minimal harm 2024-02-26

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-03-26

D · Potential for more than minimal harm 2024-02-26

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 2024-03-26

D · Potential for more than minimal harm 2023-12-20

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-01-11

D · Potential for more than minimal harm 2023-09-21

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2023-10-03

E · Potential for more than minimal harm 2022-10-04

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 2022-11-08

E · Potential for more than minimal harm 2022-10-04

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2022-11-08

E · Potential for more than minimal harm 2022-10-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-11-08

E · Potential for more than minimal harm 2022-10-04

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2022-11-08

D · Potential for more than minimal harm 2022-10-04

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 2022-11-08

D · Potential for more than minimal harm 2022-10-04

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 2022-11-08

D · Potential for more than minimal harm 2022-10-04

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-11-08

D · Potential for more than minimal harm 2022-10-04

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-11-08

D · Potential for more than minimal harm 2022-10-04

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 2022-11-08

Penalties and ownership

What sits behind the stars

Ownership

Beddoe, Marvin

Operational/Managerial Control · Individual

0% 22 facilities 2010-04-01
Nordstrom, Jodi

Operational/Managerial Control · Individual

0% 1 facilities 1996-07-08
Rapp, Andrew

Operational/Managerial Control · Individual

0% 7 facilities 2016-03-08
Raskind, Daniel

Operational/Managerial Control · Individual

0% 2 facilities 2019-10-01
Regency Pacific Management LLC

Operational/Managerial Control · Organization

0% 19 facilities 2010-04-01

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