Cycle 1
Health 2025-05-23 · Fire 2025-05-23
17 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Olympia, WA
Regency Olympia Rehabilitation And Nursing Center
4-star overall rating with 3-star inspections with $8,278 in total fines with 17 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1811 East 22nd Avenue, Olympia, WA
(360) 943-0910
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
28
Certified beds
Average residents
23
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Regency Pacific Management
Operator or chain grouping
Approved since
2005-06-01
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
0.84
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.77
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.58
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
4.21
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
4.41
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,293
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9877
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.19
Baseline 19.40% · Performance 18.10% · Measure score 7.19 · Achievement 7.19 · Improvement 4.97
Healthcare-associated infections
2.83
Baseline 7.43% · Performance 6.99% · Measure score 2.83 · Achievement 2.83 · Improvement 1.31
Total nurse turnover
0
Baseline 65.22% · Performance 65.79% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.22% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 5.94% · Lower 95% interval 6.26% |
| Discharge to community | 66% |
50.57%
15.4 pts better
|
Better than the National Rate · Eligible stays 104 · Observed rate 58.65% · Lower 95% interval 56.8% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 82 · Denominator 82 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 82 |
| Discharge self-care score | 77.78% |
53.69%
24.1 pts better
|
Numerator 42 · Denominator 54 |
| Discharge mobility score | 72.22% |
50.94%
21.3 pts better
|
Numerator 39 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 2.44% |
2.29%
0.1 pts worse
|
Numerator 2 · Denominator 82 · Adjusted rate 2.28% |
| Healthcare-associated infections requiring hospitalization | 6.99% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 7.14% · Lower 95% interval 4.06% |
| Staff COVID-19 vaccination coverage | 67.5% |
8.2%
59.3 pts better
|
Numerator 27 · Denominator 40 |
| Staff flu vaccination coverage | 26.32% |
42%
15.7 pts worse
|
Numerator 10 · Denominator 38 |
| Discharge function score | 70.37% |
56.45%
13.9 pts better
|
Numerator 38 · Denominator 54 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 43 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 20% |
25.2%
5.2 pts worse
|
Numerator 9 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
96.0%
0.3 pts better
|
93.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 96.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.0% |
16.3%
10.3 pts better
|
11.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.0% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
5.8%
0.2 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.6% |
12.1%
5.5 pts worse
|
19.6%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.9% |
15.9%
3 pts worse
|
16.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.9% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.9% |
15.8%
9.9 pts better
|
14.9%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.2%
1.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
1.7%
2.1 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.2% |
23.5%
11.3 pts better
|
19.8%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.2% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
4.7%
2.2 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.9% |
87.7%
1.8 pts worse
|
81.7%
4.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.1% · Q2 81.8% · Q3 87.5% · Q4 91.2% · 4Q avg 85.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
13.2%
3.4 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 11.8% · Expected 13.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.4%
0.5 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 4.9% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 71.6% |
82.0%
10.4 pts worse
|
79.7%
8.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 71.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
19.9%
4.5 pts worse
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 33.3% · Expected 32.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-08 · Fire 2024-03-08
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2023-04-06 · Fire 2023-04-06
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-10-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-10
F · Potential for more than minimal harm
2025-10-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-10
F · Potential for more than minimal harm
2025-05-23
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-06-13
F · Potential for more than minimal harm
2025-05-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-06-13
F · Potential for more than minimal harm
2025-05-23
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 2025-06-13
E · Potential for more than minimal harm
2025-05-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-13
F · Potential for more than minimal harm
2024-03-08
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-03-08
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-03-08
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-03-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-03-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-08
F · Potential for more than minimal harm
2023-04-06
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-05-10
F · Potential for more than minimal harm
2023-04-06
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-05-10
F · Potential for more than minimal harm
2023-04-06
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-05-10
F · Potential for more than minimal harm
2023-04-06
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-05-10
F · Potential for more than minimal harm
2023-04-06
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-05-10
F · Potential for more than minimal harm
2023-04-06
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-05-10
F · Potential for more than minimal harm
2023-04-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-18
F · Potential for more than minimal harm
2023-04-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-10
F · Potential for more than minimal harm
2023-04-06
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-05-10
F · Potential for more than minimal harm
2023-04-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-10
F · Potential for more than minimal harm
2023-04-06
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-05-10
F · Potential for more than minimal harm
2023-04-06
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-04-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-09-09
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 2025-09-25
F · Potential for more than minimal harm
2025-05-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-08
E · Potential for more than minimal harm
2025-05-23
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 2025-07-08
E · Potential for more than minimal harm
2025-05-23
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-07-08
E · Potential for more than minimal harm
2025-05-23
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 2025-07-08
E · Potential for more than minimal harm
2025-05-23
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-05-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-05-23
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-05-23
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 2025-07-08
D · Potential for more than minimal harm
2025-05-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-05-23
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 2025-07-08
D · Potential for more than minimal harm
2025-05-23
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 2025-07-08
D · Potential for more than minimal harm
2025-05-23
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-05-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-05-23
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 2025-07-08
D · Potential for more than minimal harm
2025-05-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-07-08
G · Actual harm
2025-01-13
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 2025-02-11
C · Minimal harm
2024-11-27
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 2024-12-21
F · Potential for more than minimal harm
2024-03-08
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-08
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 2024-04-03
D · Potential for more than minimal harm
2023-08-01
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-08-15
E · Potential for more than minimal harm
2023-04-06
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-05-09
E · Potential for more than minimal harm
2023-04-06
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 2023-05-09
D · Potential for more than minimal harm
2023-04-06
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 2023-05-09
D · Potential for more than minimal harm
2023-04-06
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 2023-05-09
Penalties and ownership
What sits behind the stars
$8,278
2025-01-13
Fine
Fine · fine $8,278
Fine
Ownership
Bd Facilities LLC
5% Or Greater Direct Ownership Interest · Organization
Beddoe, Marvin
5% Or Greater Indirect Ownership Interest · Individual
Beddoe, Marvin
Operational/Managerial Control · Individual
Regency Pacific Management LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Panorama City Conv & Rehab Ctr
Lacey, WA
5-star overall rating with 4-star inspections with $11,190 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Woodard Creek Health & Rehabilitation
Olympia, WA
1-star overall rating with 1-star inspections with 34 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Olympia Transitional Care And Rehabilitation
Olympia, WA
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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