Cycle 1
Health 2025-07-30 · Fire 2025-07-30
14 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Coupeville, WA
Regency Coupeville Rehab And Nursing Center
2-star overall rating with 2-star inspections with abuse icon flag with $144,060 in total fines with 14 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
311 Northeast 3rd Street, Coupeville, WA
(360) 678-2273
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
71
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Regency Pacific Management
Operator or chain grouping
Approved since
1987-01-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.59
Registered nurse staffing
LPN hours / resident day
1.00
Licensed practical nurse staffing
Aide hours / resident day
2.49
Nurse aide staffing
Weekend hours
3.56
Weekend nurse staffing
RN turnover
53%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.4
0.6 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 6.7 |
1.5
5.2 pts worse
|
1.8
4.9 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
96.0%
3.5 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.8% |
93.8%
3 pts better
|
95.5%
1.3 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
2.6%
0.8 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 5.5% |
16.3%
10.8 pts better
|
11.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.8%
5.8 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.6% |
12.1%
3.5 pts better
|
19.6%
11 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 6.4% |
15.9%
9.5 pts better
|
16.7%
10.3 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 | 32.1% |
20.0%
12.1 pts worse
|
16.3%
15.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.2% |
15.8%
7.6 pts better
|
14.9%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
1.2%
0.6 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.9% |
23.5%
5.6 pts better
|
19.8%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
4.7%
2.9 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.4% |
87.7%
21.3 pts worse
|
81.7%
15.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.3% |
13.2%
8.1 pts worse
|
12.0%
9.3 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.4%
0.8 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 55.4% |
82.0%
26.6 pts worse
|
79.7%
24.3 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 42.1% |
19.9%
22.2 pts worse
|
23.9%
18.2 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-29 · Fire 2024-10-29
24 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-11-22 · Fire 2023-11-22
28 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
18 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-30
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-08-28
F · Potential for more than minimal harm
2025-07-30
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2025-08-28
F · Potential for more than minimal harm
2025-07-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-28
F · Potential for more than minimal harm
2025-07-30
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
2025-07-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-17
F · Potential for more than minimal harm
2025-07-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-07-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-07-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-08-28
F · Potential for more than minimal harm
2024-10-29
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-10-29
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-10-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-10-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-10-29
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 2024-11-21
F · Potential for more than minimal harm
2024-10-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-10-29
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-10-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-24
E · Potential for more than minimal harm
2024-10-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-10-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-01
F · Potential for more than minimal harm
2023-11-22
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-22
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-22
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-22
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-01-01
F · Potential for more than minimal harm
2023-11-22
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 2023-12-12
F · Potential for more than minimal harm
2023-11-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-12
E · Potential for more than minimal harm
2023-11-22
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-12-12
E · Potential for more than minimal harm
2023-11-22
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-12
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-30
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-10
E · Potential for more than minimal harm
2025-07-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-09-10
E · Potential for more than minimal harm
2025-07-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-10
E · Potential for more than minimal harm
2025-07-30
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 2025-09-10
E · Potential for more than minimal harm
2025-07-30
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-09-10
E · Potential for more than minimal harm
2025-07-30
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 2025-09-10
D · Potential for more than minimal harm
2025-07-30
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-07-30
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-07-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-07-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-09-10
J · Immediate jeopardy
2025-06-12
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 2025-05-23
G · Actual harm
2025-06-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-06-12
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 2025-07-15
E · Potential for more than minimal harm
2025-05-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-02-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-18
F · Potential for more than minimal harm
2024-10-29
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-12-04
E · Potential for more than minimal harm
2024-10-29
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-12-04
E · Potential for more than minimal harm
2024-10-29
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-12-04
E · Potential for more than minimal harm
2024-10-29
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 2024-12-04
D · Potential for more than minimal harm
2024-10-29
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 2024-12-04
D · Potential for more than minimal harm
2024-10-29
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 2024-12-04
D · Potential for more than minimal harm
2024-10-29
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-10-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-10-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-10-29
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 2024-12-04
D · Potential for more than minimal harm
2024-10-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-10-29
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-10-29
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 2024-12-04
D · Potential for more than minimal harm
2024-10-29
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-12-04
E · Potential for more than minimal harm
2024-09-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-29
E · Potential for more than minimal harm
2024-09-27
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 2024-10-29
D · Potential for more than minimal harm
2024-09-27
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 2024-10-29
D · Potential for more than minimal harm
2024-09-27
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 2024-10-29
D · Potential for more than minimal harm
2024-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-09-06
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-04-05
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 2024-05-07
D · Potential for more than minimal harm
2024-04-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-07
G · Actual harm
2023-11-22
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 2024-01-17
E · Potential for more than minimal harm
2023-11-22
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 2024-01-17
E · Potential for more than minimal harm
2023-11-22
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-11-22
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 2024-01-17
E · Potential for more than minimal harm
2023-11-22
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 2024-01-17
E · Potential for more than minimal harm
2023-11-22
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 2024-01-17
E · Potential for more than minimal harm
2023-11-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-11-22
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 2024-01-17
E · Potential for more than minimal harm
2023-11-22
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-11-22
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-11-22
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 2024-01-17
E · Potential for more than minimal harm
2023-11-22
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 2024-01-17
E · Potential for more than minimal harm
2023-11-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-22
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 2024-01-17
D · Potential for more than minimal harm
2023-11-22
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 2024-01-17
D · Potential for more than minimal harm
2023-11-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-22
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 2024-01-17
D · Potential for more than minimal harm
2023-11-22
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 2024-01-17
D · Potential for more than minimal harm
2023-11-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-22
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-22
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 2024-01-17
D · Potential for more than minimal harm
2023-11-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-22
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-22
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-22
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-11-22
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 2024-01-17
Penalties and ownership
What sits behind the stars
$14,015
2025-05-22
Fine
Fine · fine $14,015
Fine
$22,925
2025-05-22
Fine
Fine · fine $22,925
Fine
$0
2024-09-06
Payment Denial
Payment Denial · denial start 2024-12-06 · 5 days
5 day denial
$107,120
2023-11-22
Fine
Fine · fine $107,120
Fine
Ownership
Beddoe, Marvin
5% Or Greater Direct Ownership Interest · Individual
Clay, James
5% Or Greater Direct Ownership Interest · Individual
Stroud, David
5% Or Greater Direct Ownership Interest · Individual
Beddoe, Marvin
Operational/Managerial Control · Individual
Chu, Caleb
Operational/Managerial Control · Individual
Moffitt, Eric
Operational/Managerial Control · Individual
Rapp, Andrew
Operational/Managerial Control · Individual
Regency Pacific Management LLC
Operational/Managerial Control · Organization
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#3
Soundview Rehabilitation And Health Care Inc
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2-star overall rating with 2-star inspections with 11 recent health deficiencies with 23 fire-safety deficiencies in the latest cycle
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