Home / Washington / Sequim
1000 5th Avenue South, Sequim, WA 98382 · Clallam County · (360) 582-3900
90 certified beds, about 70 residents a day · For profit - Corporation · Medicare and Medicaid since 1989
CMS Care Compare ratings, data as of September 1, 2026 · CCN 505327 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on December 9, 2025, inspectors cited 24 health deficiencies (the Washington average is 15.8, the national average 9.2).
Of 62 health citations since August 2023, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $48,828 in the last three years; the largest was $48,828, and the latest is dated December 9, 2025.
Nurses and nurse aides worked 4.63 hours per resident per day, against 4.36 across Washington and 3.86 nationally. Registered nurses accounted for 1.18 of those hours.
37.2% of nursing staff left within the year CMS measured (Washington average 45.1%).
CMS links it to Avamere, an affiliated group of 27 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 62 health citations on file.
Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient nursing staff were available to provide assistance in a timely manner without long wait times, as evidenced by facility grievance records, and staff and resident interviews for 2 of 3 units (Units 1 and 3) reviewed for care related concerns. These failures placed residents at risk for unmet care needs and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide bowel care in accordance with provider orders and the facility's bowel protocol for 2 of 4 residents (Resident 1 & 2) reviewed for bowel management. This failure placed residents at risk for abdominal pain/discomfort, decreased appetite and other potential health complicationsFindings included. Review of the undated facility policy titled, Bowel Protocol for Constipation, showed that additional interventions would be initiated on Day 3 for a resident not having a recorded bowel movement (BM). Interventions included use of a stool softener or stimulant laxative, if no results on day 4, MiraLAX or Milk of Magnesia would be initiated, day 5 use of a suppository and day 6 administration of an enema. Resident 1Resident 1 was admitted to the facility on [DATE]. [...]
Inspectors wroteBased on interviews and observations the facility failed to provide a clean, homelike environment for 2 of 5 (East, West) shower rooms reviewed for clean and homelike environment, by not maintaining the condition and appearance of the room to meet expected standards. These failures place residents at risk for potential exposure to unidentified substances, diminished mood, and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to adequately and consistently assess developing/worsening skin conditions/breakdown, follow the care/treatment plan and interventions as ordered, and report changes to medical provider in a timely manner for 1 of 1 sampled resident (Resident 24) reviewed for pressure ulcers. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were sent to the hospital with the required and necessary information to assure the safe transition of care for 3 of 3 residents (Residents 52, 81, & 1) reviewed for hospitalization. This failure placed residents at risk of incomplete emergency care, lack of services, lack of advocacy, and a diminished quality of care.
Inspectors wroteBased on observation and interview the facility failed to provide appetizing and palatable food for 7 of 24 sampled residents (5, 17, 24, 11, 84, 10, and 28) and 1 of 1 test tray sampled for food quality. The facility also failed to prepare pureed foods for residents following the written recipe to ensure the nutritional value was maintained. These failures placed residents at risk for a decline in nutrition and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Sets (MDS, an assessment tool) accurately reflected residents' health status and care needs for 5 of 22 sample residents (Residents 7, 26, 2, 8 & 12) whose assessments were reviewed. These failures placed residents at risk for unidentified and/or unmet care needs and decreased quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' care plans were comprehensive and person centered for 7 of 22 sampled residents (Residents 52, 54, 12, 1, 7, 73 & 9) reviewed for care plans. This failure placed residents at risk of lack of services or cares, and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards were met related to following provider orders, medication administration practices, provider notification of weight variances, and/or accurate documentation practices, for 7 of 22 sampled residents (Resident 73, 1, 31, 12, 74, 9 & 24). This failure placed residents at risk of not receiving services being signed off on, lack of monitoring, medication complications, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide restorative services at the assessed frequency, for 2 of 2 residents (Residents 52 & 54) reviewed for restorative services. This failure placed residents at risk of decreased range of motion, loss of abilities to complete daily activities, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure staff monitored and accurately recorded fluid intake for 1 of 1 resident (Resident 3) reviewed for hydration. These failures placed residents at potential risk for medical complications, fluid overload, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure peripherally inserted central catheters (PICC, a long, flexible tube inserted into a vein in the arm, used for prolonged intravenous access to deliver medications, fluids, and nutrition) were assessed, maintained and monitored in accordance with professional standards of practice for 2 of 2 residents (Residents 73 & 84) reviewed for IV therapy. This failure placed residents at risk for unidentified complications, loss of vascular access, infection, and other potential negative health outcomes.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen therapy was provided in accordance with physician's orders and accepted professional standards of practice for 1 of 1 resident (Resident 73) reviewed for respiratory care and services. The failure to document when oxygen was administered, to check and replace empty portable oxygen cylinders, and ensure humidifier bottles contained fluid and were functional, placed residents at risk for respiratory compromise and/or unmet respiratory needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to reevaluate the necessity and safety of bed rails/mobility bars for 2 of 2 residents (Residents 12 & 8) reviewed for bed rails. This failure placed residents at risk of accidents and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure monthly pharmacist recommendations were carried out accurately and timely, for 1 of 5 residents (Resident 12) reviewed for unnecessary medications. This failure placed residents at increase for accidents, unnecessary medication, complications, and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was properly stored and labeled in refrigerators, food temperatures were checked without preventing cross contamination, and the resident snack refrigerators were monitored in accordance with professional standards for safe food service. These failures placed the residents at potential risk for food borne illnesses, and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' records were accurate and complete for 10 of 24 sampled residents (Resident 9, 81, 6, 52, 10, 26, 31, 7, 1, & 37) reviewed for resident records. The failure to document resident information accurately and completely, and/or correctly identify residents' primary care physician, placed the resident at risk for incomplete and inaccurate medical records and unmet care needs.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed standard precautions (common sense practices to prevent the spread of infection in healthcare) and enhanced barrier precautions (EBP, a set of infection control measures that use gowns and gloves to reduce the spread of multidrug resistant organisms and precautions that are implemented when someone has chronic wounds or confirmed or suspected infections). Additionally, the facility failed to perform infection surveillance for 1 of 1 resident (Resident 52) reviewed for surveillance. This failure placed residents at risk of undetected infection, spread of infection, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure safety devices were consented for 1 of 2 residents (Resident 12) reviewed for safety devices/bed rails. This failure placed residents at risk of uninformed consent, increased chance of accidents, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice and their comprehensive care plans for 4 of 22 sampled residents (Residents 1, 3, 8 & 81). The failure to initiate bowel care, identify and monitor non-pressure skin conditions, complete and document respiratory assessments, and evaluate daily weights and report significant variances to the physician, placed resident at risk for unidentified and/or avoidable decline, delay in treatment, pain/discomfort, unmet care needs and other potential negative health outcomes.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from accident hazards for 4 of 5 residents (Residents 12, 73, 59 & 17) reviewed for accident hazards. This failure placed residents at an increase for falls, injury, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with urinary catheters (a flexible tube inserted into the bladder to drain urine) received appropriate care and monitoring for pre and post hospitalization, including following the hospital's discharge plan of care, to prevent or treat urinary tract infections (UTIs) for 2 of 4 residents (Resident 6 & 52) reviewed for urinary catheters and hospitalization. These failures placed residents at risk for hospitalization, urinary tract infections, urethral erosion and a decreased quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care was provided in accordance with professional standards, by not providing urostomy (urinary diversion, which is a surgical procedure to create an opening (stoma) on the abdomen to allow urine to exit the body when the bladder is not functioning or has been removed. The urine is then collected in a pouch attached to the stoma) supplies for 1 of 1 sample resident (Resident 10) reviewed for urostomy care. This failure placed the resident at risk for unmet care needs and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to complete annual performance reviews as required for 5 of 5 Certified Nursing Assistants (CNA) (Staff EE, FF, GG, HH & II) who were reviewed. Failure to complete annual performance evaluations did not ensure staff were adequately trained, and placed residents at risk for unmet care needs.
Inspectors wroteBased on observation and interview, the facility failed to maintain locked medication carts for 1 of 5 medication storage carts (Pine Ave Nurses station) when reviewed for medication storage. This failure placed the residents at risk for missing medications, medication discrepancies and impaired quality of life.
Inspectors wroteBased on interview and record review, the facility failed to implement an Antibiotic Stewardship Program with monitoring, documentation, reevaluation and/or education for three of three months (August 2025, September 2025, and October 2025) reviewed, and for 1 of 1 resident reviewed (Resident 8) for prophylactic (usage to prevent disease) antibiotic usage. This failure placed residents at risk for unnecessary antibiotics, an increased risk of infections and a decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to develop, implement and maintain an in-service training program that ensured nursing assistants (NA) completed the required 12 hours of annual Inservice training for 1 of 5 NAs (Staff EE) reviewed for annual training hours. The failure to ensure NAs completed 12 hours of annual training as required, placed residents at risk of receiving inadequate care.
Inspectors wroteBased on interviews and record reviews, the facility failed to identify and prevent an allegation of neglect, failed to suspend staff members alleged to have neglected residents and failed to initiate the investigation and assess and monitor residents in a timely manner for three of three residents (Residents 1, 2 and 3) reviewed for neglect. These failures placed residents at risk for continued neglect and a diminished quality of life.
Inspectors wroteBased on interviews and record review, the facility failed to ensure activities of daily living (ADLs) pertaining to bathing/showers were provided for dependent residents for 5 of 9 residents (4, 5, 6, 7, and 8) reviewed for ADL care. This failure placed residents at risk of not receiving the care and services needed for which they were unable to perform themselves and a diminished quality of life.
Inspectors wroteBased on interview and record review the facility failed to provide care and services consistent with professional standards for 2 of 9 Residents (Residents 1 and 2) reviewed for Quality of Care when the facility staff failed to monitor the residents for psychosocial harm following allegations against staff members. This failure placed all residents at risk for psychosocial harm, unmet care needs and decreased quality of life.
Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective infection control program by ensuring staff had appropriate personal protective equipment (PPE) available for 3 of 3 units and that staff donned (put on) appropriate PPE for residents on droplet precautions (infection control precaution of wearing mask and eye protection upon entering the room and gown and gloves for potential for exposure to secretions) for 2 of 5 residents (Resident 3 and 9) reviewed for infection control practices. Also, the facility failed to include the Infection Preventionist (IP) on the water management panel and ensure all control measures of the Legionella Water Management Program were implemented when routine chlorine testing and routine resident room faucet inspections and cleaning were not performed. [...]
Inspectors wroteBased on interview, and record review, the facility failed to ensure there were sufficient qualified nursing staff to provide restorative nursing services for 16 of 16 residents (Residents 41, 28, 21, 29, 20, 23, 26, 34, 9, 18, 33, 48, 2, 172, 39 and 10) reviewed for restorative nursing. Additionally, review of Resident Council Minutes for June, July and August 2024, showed 3 of 3 months contained resident complaints related to staffing. The failure to have sufficient qualified nursing staff to respond timely to resident call lights and care needs, and that ensured the provision of restorative nursing programs (RNPs) residents had been assessed to require, placed residents at risk for a decline in strength, range of motion, contracture formation, increased dependence on staff for activities of daily living (ADLs), unmet care needs and decreased quality of life.
Inspectors wroteBased on interviews and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the residents' mental health conditions for 3 of 6 sampled residents (Residents 25, 63, and 171) reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure restorative nursing programs (RNPs) to increase, maintain and/or prevent decline in range of motion (ROM ), strength and mobility were provided for 16 of 16 residents (Residents 41, 28, 21, 29, 20, 23, 26, 34, 9, 18, 33, 48, 2, 172, 39 and 10) reviewed, who were assessed to require them in December 2023, when the facility stopped providing restorative services due to staffing issues. Additionally, after the facility reimplemented restorative nursing services, they failed to provide a restorative range of motion program at the frequency the resident was assessed to require for 1 of 1 resident (Resident 2) reviewed. [...]
Inspectors wrote<Resident 62> Resident 62 admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 07/13/2024, showed the resident was cognitively intact, had diagnoses of depressive (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorders (repeated episodes of intense anxiety, fear or terror) and received antidepressant and antianxiety medications during the assessment period. Review of Resident 62's electronic health record (EHR) showed the following psychotropic medication orders: a) 08/05/2024 order for mirtazapine (an antidepressant) daily at bedtime for major depression. b) 07/09/2024 order for Seroquel (an antipsychotic) daily at bedtime for unspecified dementia with other behavioral disturbances. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store drugs and biologicals used in the facility in accordance with current accepted professional principles for 2 of 3 medication carts ([NAME] & Dungeness) and 1 of 3 medication rooms (One) reviewed for medication storage and labeling, and 1 of 21 rooms for sampled residents (Resident 27). This failure placed residents at risk for decrease effectiveness of medication, worsening symptoms, unidentified complications, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were complete accurate and readily accessible for 16 of 16 residents (Residents 41, 28, 21, 29, 20, 23, 26, 34, 9, 18, 33, 48, 2, 172, 39 and 10) reviewed for restorative services and for 1 of 1 Resident (Resident 11) reviewed for Hospice services. The facility failed to maintain documentation of the provision of restorative nursing services for residents who were assessed to require them. Additionally, the facility failed to maintain hospice documentation inlcuding details regarding coordination with hospice services, hospice recertification and details regarding visits by hospice staff. These failures resulted in residents' health records being incomplete and/or inaccurate and placed residents at risk for unmet care needs and potential negative health outcomes.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed of the risks and benefits associated with proposed psychotropic medication therapy (medications capable of affecting the mind, emotions, and behavior), and obtain the residents'/resident representatives' consent prior to administering the medication for 2 of 6 residents (Residents 62 and 63) reviewed for unnecessary medications. This failure prevented residents from making an informed decision about the use of the proposed medication and precluded the resident from exercising their right to decline such treatment therapy and from exercising their right to refuse/decline the proposed medication.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide adaptive equipment for cutting food that reflected the unique physical needs and preferences for 1 of 1 resident (Resident 63) reviewed for accommodation of needs. The facility failed to implement a plan for the resident's living environment that was conducive to their unique physical limitations and that took into consideration their needs and preferences which placed them at risk for a diminished quality of life and increased dependence on staff.
Inspectors wroteBased on interview and record review, the facility failed to address required documentation for advance directives (AD) for 2 of 5 residents (Residents 2 and 40) reviewed for advanced directives. This failure placed the residents at risk of losing their right to have their preferences/decisions honored for end-of-life care.
Inspectors wroteBased on interview and record review, the facility failed to initiate and investigate grievances for resident concerns, maintain an accurate log of grievances and report grievances to the Administrator for review for 2 of 2 sampled resident (Residents 27 and 63) and 1 of 1 resident groups (Resident Council) reviewed for grievances. This failure to report, initiate, investigate, and log grievances placed residents at risk for not having grievances investigated, delayed or incomplete resolution to grievances and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure allegations of abuse and neglect were reported to the state agency for 1 of 4 sampled residents (Resident 46) reviewed for abuse/neglect. This failure placed residents at risk for experiencing potential abuse and neglect and a diminished quality of life.
Inspectors wroteBased on interview and record review the facility failed to properly notify the Office of the State Long-Term Care Ombudsman of the discharge or transfer for 1 of 5 residents (Resident 40). This failure placed the residents at risk for diminished protection from being inappropriately discharged , lack of access to an advocate who can inform them of their options and rights, and to ensure that the Offices of the State Long-Term-Care Ombudsman is aware of facility practices and activities related to transfers and discharges.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident assessments accurately reflected their health status and/or care needs for 3 of 33 sample residents (Residents 11, 4 & 2) whose Minimum Data Sets (MDS, an assessment tool) were reviewed. The failure to accurately assess whether residents had a terminal diagnosis, that residents were receiving restorative therapy or were on a physician ordered planned weight loss program, placed residents at risk for unidentified and/or unmet care needs.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 5 of 33 sampled residents (Residents 30, 10, 62, 42 & 54) reviewed for professional standards. The failure to follow and/or clarify incomplete physicians' orders, and to only sign for tasks that were completed, placed residents at risk for medication errors, complications of treatments, and other potential negative health outcomes.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) for 1 of 3 residents (Resident 58) reviewed for ADLs. Failure to provide assistance with oral care to residents who were dependent on staff for such care, placed the residents at risk for unmet needs, poor hygiene, diminished self-image, and decreased quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 4 of 15 sample residents (Residents 30, 10, 62, and 63) received the necessary care and services in accordance with their comprehensive person-centered plan of care. The facility's failure to ensure residents received the care and services they were assessed to require related to edema management (Resident 30), treatment and monitoring of non-pressure skin issues (Resident 10 and 62), and positioning (Resident 63) placed residents at risk for wound decline and/or prolonged wound healing times, poorly controlled edema (swelling), delays in treatment, unmet care needs and decreased quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pressure ulcer care consistent with professional standards of practice to prevent and treat pressure ulcers for 1 of 3 sampled residents (Resident 4) reviewed for pressure ulcers. This failure placed residents at risk for developing pressure ulcers, worsening pressure ulcers, increased pain, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document, monitor and assess resident fluid intake, to follow physician orders to obtain weights, implement nutritional interventions, and reevaluate the effectiveness of the interventions for 2 of 5 sampled residents (Resident 4 & 62) reviewed for nutrition/hydration. These failures placed residents at risk for fluid volume overload, fluid and electrolyte imbalances, unplanned significant weight loss, nutritional complications and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure that cognitively impaired residents had social services to assist with obtaining a legal representative, for 1 of 21 sampled residents reviewed (Resident 171). This failure placed residents at risk for not being able to provide informed consent, confusion, unidentified and unmet care needs, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to have a system in place that ensured effective communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 1 of 1 resident (Resident 11) reviewed for hospice services. The facility failed to obtain and/or maintain a copy of a resident's current hospice coordinated plan of care, to have documentation in residents' electronic health records that showed what hospice disciplines (e.g. registered nurse, chaplain, certified nursing assistant, massage therapist) had visited, when they visited, and what care was provided. These failures detracted from staffs' ability to effectively collaborate, communicate and coordinate care with the Hospice provider and placed residents at risk for not receiving necessary care and services and/or unmet care needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain essential equipment in working condition for 1 of 5 refrigerators in the facility's kitchen and 2 of 4 resident nourishment refrigerators (A & B) at each nursing station. Additionally, the facility failed to maintain hot water temperatures at safe levels in 4 of 7 occupied resident rooms (102, 123, 214 & 203) and 1 of 2 dining rooms ([NAME]) reviewed for functional essential equipment. These failures placed residents at risk for food borne illness or for serious burns and decreased quality of life. Findings Included <Facility's Kitchen Refrigerator> During an interview with Staff W, Kitchen Manager, on 09/25/2024 at 11:40 AM, the digital thermometer of one refrigerator (A) read 47 degrees Fahrenheit (F) The potentially hazardous foods inside Refrigerator (A) were temped: [...]
Inspectors wroteBased on interview, and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 3 sampled residents (Resident 1) reviewed for quality of care when the facility failed to clarify a medication order that was entered incorrectly. This failure placed residents at risk for receiving medication at a higher dose than ordered, potential medical complications, and a decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's representative were notified of significant changes related to abnormal lab values for 1 of 3 sample residents (Resident 1) reviewed for notification of changes. This failure placed residents and their representatives at risk of not being able to participate in resident care decisions, delayed medical treatment, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure investigations were initiated for injury of unknown origin for 1 of 3 sampled residents (Resident 1) reviewed for completing thorough investigations. This failure placed residents at risk for injury, pain, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring for anticoagulant (blood thinner) medication complications and side effects were completed for 6 of 6 sampled residents (16, 19, 44, 49, 63 & 233) reviewed for unnecessary medications related to anticoagulant medications. This failure placed residents at risk for adverse side effects from anticoagulant medication use and a diminished quality of life.
Inspectors wroteBased on observation and interview, the facility failed to ensure general infection control practices were implemented to prevent the spread of COVID-19 (a highly contagious infectious disease) for 2 of 3 halls (Greywolf hall and 300 hall) and failed to ensure staff completed hand hygiene when required during wound care for 1 of 1 sampled residents (Resident 9) reviewed for infection prevention and control. These failures placed residents at risk of infection from COVID-19, wound complications and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a written bed-hold notice was provided to the resident or resident's representative at the time of transfer to the hospital for 1 of 2 sampled residents (9) reviewed for bed-hold notification. This failure placed residents and resident representatives at risk of not being informed regarding their right to hold their bed while in the hospital.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR), a screening tool used to identify mental health needs, was accurate for 1 of 5 sampled residents (44) reviewed for PASARR. This failure placed residents at risk for not receiving specialized mental health services, unidentified mental health needs and a decreased quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fall prevention strategies were implemented before a fall with injuries and failed to monitor and follow the treatment plan after a fall with injury for 1 of 2 sampled residents (Resident 19) reviewed for accident hazards. This failure place residents at risk for injuries, unmet care needs, and a diminished quality of life.
Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored in a manner allowing accurate accounting of pills for 2 of 3 medication carts ([NAME] and Pine) reviewed for medication storage. This failure placed residents at risk of financial exploitation from missing medication.
Inspectors wroteBased on observation and interview, the facility failed to ensure food items were stored [NAME] accordance with professional standards when items were labeled and dated when opened in 1 of 3 nourishment refrigerators (Unit 300) reviewed for food safety. This failure placed residents at risk for cross-contamination and food borne illness.
18 fire safety citations on file: 2 on December 9, 2025, 5 on October 1, 2024, 11 on August 11, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| December 9, 2025 | Fine | $48,828 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Washington | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.63 | 4.36 | 3.86 |
| Registered nurses | 1.18 | 0.94 | 0.69 |
| All nursing staff on weekends | 3.96 | 3.80 | 3.42 |
| Nurse aides | 2.82 | ||
| Licensed practical nurses | 0.63 | ||
| Nursing staff turnover (share who left in a year) | 37.2% | 45.1% | 45.8% |
| Registered nurse turnover | 35.0% | 45.4% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.97 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.90 on weekdays and 3.96 on weekends, 19% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.95 in April to June 2025 to 4.63 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.63 | 1.18 | 4.90 | 3.96 | 0.0% | 0 of 90 | 70 |
| Oct to Dec 2025 | 4.60 | 1.14 | 4.82 | 4.02 | 0.0% | 0 of 92 | 71 |
| Jul to Sep 2025 | 5.06 | 1.23 | 5.34 | 4.35 | 0.4% | 0 of 92 | 66 |
| Apr to Jun 2025 | 4.95 | 1.08 | 5.21 | 4.30 | 1.5% | 0 of 91 | 71 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Washington, Jan to Mar 2026 | 4.21 | 0.90 | 4.44 | 3.66 | 3.7% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Washington, all employers | |||
| CNAs (nursing assistants) | $23.65 | $22.59 to $27.85 | 30,270 |
| LPNs and LVNs | $39.98 | $36.98 to $45.18 | 6,780 |
| Registered nurses | $59.71 | $49.57 to $64.54 | 69,260 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Washington | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 17.8 | 14.2 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.6 | 1.0 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 3.3 | 1.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.2 | 2.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.5 | 1.3 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 20.2 | 17.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.8 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 8.8 | 15.1 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 22.9 | 19.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 20.2 | 13.4 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.0 | 1.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.2 | 1.5 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Avamere Olympic Rehabilitation of Sequim's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (61.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
61.4% this home
Better than the national rate
US median of homes 51.5% · Washington: 71 better, 16 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 406 eligible stays.
8.9% this home
No different from the national rate
US median of homes 10.7% · Washington: 7 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 398 eligible stays.
7.7% this home
No different from the national rate
US median of homes 7.1% · Washington: 4 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 257 eligible stays.
67.2% this home
Median of homes: Washington61.4% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 177 residents counted.
0.9% this home
Median of homes: Washington0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 233 residents counted.
1.1% this home
Median of homes: Washington1.4% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 233 residents counted.
98.0% this home
Median of homes: Washington98.3% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 153 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: SEQUIM REHABILITATION LLC. CMS links this home to Avamere, a group of 27 nursing homes averaging 3 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Avamere Health Services LLC | 5% or greater direct ownership interest | Organization | 100% | 09/01/2007 |
| Dillon, Richard | 5% or greater indirect ownership interest | Individual | 26% | 01/01/2007 |
| Hilty, Matthew | 5% or greater indirect ownership interest | Individual | 6% | 01/01/2018 |
| Odermott, Ronald | 5% or greater indirect ownership interest | Individual | 6% | 02/01/2013 |
| Wart, Gary | 5% or greater indirect ownership interest | Individual | 9% | 01/10/2013 |
| Dillon, Richard | W-2 managing employee | Individual | 01/01/2007 | |
| Jeffers, Heather | W-2 managing employee | Individual | 01/01/2014 | |
| Miller, Karl | W-2 managing employee | Individual | 01/01/2007 | |
| Dillon, Richard | Corporate director | Individual | 12/29/2004 | |
| Jeffers, Heather | Corporate director | Individual | 06/01/2018 | |
| Miller, Karl | Corporate director | Individual | 01/01/2007 | |
| Dillon, Richard | Corporate officer | Individual | 01/01/2007 | |
| Hilty, Matthew | Corporate officer | Individual | 08/01/2018 | |
| Odermott, Ronald | Corporate officer | Individual | 09/01/2017 | |
| Wart, Gary | Corporate officer | Individual | 09/01/2017 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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