Home / Washington / Tacoma
3919 South 19th Street, Tacoma, WA 98405 · Pierce County · (253) 752-5677
139 certified beds, about 98 residents a day · For profit - Corporation · Medicare and Medicaid since 1976
CMS Care Compare ratings, data as of September 1, 2026 · CCN 505239 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on July 2, 2025, inspectors cited 18 health deficiencies (the Washington average is 15.8, the national average 9.2).
Of 74 health citations since August 2023, 3 were rated as actual harm or immediate jeopardy to residents.
CMS lists 2 fines totaling $241,815 in the last three years; the largest was $174,304, and the latest is dated September 18, 2024.
Nurses and nurse aides worked 5.14 hours per resident per day, against 4.36 across Washington and 3.86 nationally. Registered nurses accounted for 0.96 of those hours.
49.1% of nursing staff left within the year CMS measured (Washington average 45.1%).
CMS links it to Regency Pacific Management, 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 74 health citations on file.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) program self-identified deficiencies and failed to develop/implement effective plans of action to sustain plan of corrections for previous deficiencies. Failure to have an effectively functioning QAPI program that consistently self-identified deficient practices led to repeated deficiencies, and a pattern of deficiencies that placed residents at repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care.
Inspectors wroteResident 95 Review of the EHR showed Resident 95 admitted to the facility on [DATE] with diagnoses to include respiratory failure, hemiplegia (paralysis/loss of muscle function) and (partial paralysis or muscle weakness) of one side of the body following a stroke (blood flow to the brain suddenly interrupted). Resident 95 was able to make needs known. During an interview on 06/25/2025 at 10:39 AM, Resident 95 stated they had a stroke and the left side of their body was weak. Review of the minimum data set (MDS, a required assessment tool) dated 05/14/2025 showed Resident 95 received occupational therapy (OT) and physical therapy (PT) services and did not receive restorative nursing services. Review showed Resident 95 was dependent on staff for dressing the upper and lower body to include putting on and taking off footwear. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure new interventions were developed to reduce fall incidents for 1 of 3 sampled residents (Resident 12), failed to ensure elopement precautions were in place for 1 of 3 halls (100 Hall), and failed to ensure medication carts were secured for 1 of 6 medication carts (300 Hall) when reviewed for accident hazards. These failures placed residents at risk of continual falls, avoidable injury, elopement, unintended access to medications, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' nutritional status was accurately monitored for 3 of 5 sampled residents (Residents 16, 51, and 44) when reviewed for nutrition. This failure placed residents at risk of unintended wight loss, fluid overload, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to manage pain by inconsistently monitoring and/or providing non-pharmacological interventions (NPI, health interventions/approaches used instead of medication) for 4 of 6 sampled residents (Residents 95, 99, 98, and 74) reviewed for unnecessary medications and/or pain management. This failure placed the residents at risk of having unmet pain needs, receiving unnecessary medications, avoidable medication side effects, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient staff to ensure residents received timely call light responses for 3 or 3 sampled hallways (100, 300 and 400) when reviewed for staffing. This failure placed residents at risk for accidents, injuries and diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary food storage in the facility kitchen and 1 of 2 resident refrigerators (400 Hall) when reviewed for safe/sanitary food storage. This failure placed residents at risk of consuming expired food goods, foodborne illness, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to have signed consent prior to administering mood altering medication for 1 of 5 sampled residents (Resident 98) when reviewed for unnecessary medication use. This failure placed the resident or their legal representative at risk of receiving medications without knowledge to make informed decisions regarding the use of the medication, adverse side effects, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to timely complete an investigation for 1 of 3 sampled residents (Resident 95) when reviewed for accidents related to falls. Failure to ensure Resident 95's fall incident report interventions, investigation summary, and conclusion were completed timely placed the resident at risk for delay in providing interventions, unmet needs, subsequent falls, and a decrease in quality of life.
Inspectors wroteBased on record review and interview, the facility failed to provide written bed hold notice at the time of transfer to the hospital for 1 of 2 sampled residents (Resident 12) reviewed for hospitalization. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected the status for 1 of 20 sampled residents (Resident 14) reviewed for accuracy of assessments. 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 ensure a care plan was reviewed and revised timely for 1 of 3 sampled residents (Resident 95) reviewed for accidents related to falls. Failure to timely revise/update Resident 95's care plan after a fall placed the resident at risk of subsequent falls, injuries, unmet needs, and a diminished quality of life
Inspectors wroteResident 34 Resident 34 admitted to the facility on [DATE] with diagnoses that included aphasia (a language disorder that affects communication due to brain injury or stroke) chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs) depression and dementia (a decline in mental ability that interferes with daily life). Resident 34's daily decision making was severely impaired. Review of Resident 34's EHR showed a provider's order dated 03/24/2022, for citalopram (an antidepressant medication) for major depressive disorder. The EHR also showed a provider's order, dated 02/20/2025, for Seroquel (an antipsychotic mediation) for dementia with behavioral disturbance. Observations on 06/25/2025 at 9:20 AM, 12:43 PM and 2:45 PM showed Resident 34 slept in bed. Observations on 06/27/2025 at 8:45 AM and 12:07 PM showed Resident 34 slept in bed. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to apply a brace/splint (a device used to immobilize and support a body part) and an offloading boot (a specialized orthopedic device designed to reduce wight bearing pressure on a specific area of the foot or ankle) per provider orders and comprehensive care plan for 1 of 4 sampled residents (Resident 95) reviewed for position/mobility. These failures placed Resident 95 at risk for medical complications, unmet needs, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment conducive to healing of a pressure ulcer for 1 of 3 sampled residents (Resident 37) when reviewed for pressure ulcer. This failure placed residents at risk of difficulty healing, worsening pressure ulcers, and a diminished quality of life.
Inspectors wroteResident 12 Review of the EHR showed Resident 12 admitted to the facility on [DATE] with diagnoses that included chronic pain, diabetes (too much sugar in the blood) and dementia (a decline in mental ability that interferes with daily life). Resident 12 was able to make needs known. Observation on 06/24/2025 at 9:49 AM and 06/25/2025 at 2:28 PM showed Resident 12 sat in their wheelchair with oxygen being administered at two liters via nasal canula connected to an oxygen concentrator (medical device that provides supplemental oxygen). Review of Resident 12's provider's orders showed no order for oxygen. During an interview on 06/25/2025 at 12:34 PM, Staff D, RCM/LPN, reviewed the EHR and stated there was no provider's order and it must have been missed when Resident 12 returned from the hospital. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage and labeling of insulin (injectable medication that regulates blood sugar) in 1 of 3 medication carts (300 hall/front cart) when reviewed for medication storage. This failure placed residents at risk of receiving expired medications, ineffective treatment, and diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily nurse staffing was consistently posted to include the actual nursing staff hours worked. This failure caused the facility's staffing information not to be readily available to residents and visitors who may wish to review it.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services by transcribing orders with stop dates for medications that should be on-going for 1 of 5 sampled residents (Residents 1) reviewed for pharmacy services and the facility failed to consistently reconcile controlled medications correctly for 1 of 5 sampled residents (Resident 2) reviewed for medication storage. These failures placed residents at risk for inadequate and/or ineffective treatment of underlying medical conditions, risk for misappropriation/diversion of controlled medications, and other negative health outcomes.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders and perform scheduled central line dressing changes for 2 of 10 sampled residents (Residents 1 and 2) reviewed for Peripherally Inserted Central Catheter (PICC) line (a long thin tube inserted through a vein in your arm and passed through to the larger veins near the heart) management. The failure placed residents at risk for infection, medical complications, and a decreased quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 3 of 3 staff members (Staff B, C and D) used personal protective equipment (PPE) in accordance with the Centers for Disease Control (CDC) guidelines when caring for residents with known COVID 19 (an infectious virus causing respiratory illness) infections and failed to ensure 1 of 3 staff (Staff E) performed hand hygiene during care. This failure placed residents at risk of infection and contracting and spreading COVID 19.
Inspectors wroteBased on interview and record review, the facility failed to inform the resident's representative in advance of physician visits and changes to the plan of care for 1 of 3 residents (Resident 1) reviewed for resident rights. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about care, lack of advocacy, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents consistently received restorative care (movement of joints to maintain range of motion) to maintain or prevent declines in mobility for 2 of 3 residents (Residents 1 and 5) reviewed for range of motion (ROM)/mobility. This failure placed residents at risk for decreased mobility, pain and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to act on the consultant pharmacist's drug regimen review recommendations for 1 of 3 residents (Resident 1) reviewed for pharmacy services. This failure placed residents at risk for experiencing adverse side effects, medical complications, and a decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to administer a medication in accordance with provider orders for 1 of 3 residents (Resident 1) reviewed for medications. This failure placed residents at risk for medical complications, adverse side effects and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was managed in accordance with provider's orders and professional standards of practice to ensure correct placement prior to administering medications, manage the amount of fluids received and implement as needed (PRN) provider's orders for 4 of 4 sampled residents (Residents 33, 73, 77, and 7) reviewed for enteral nutrition. Resident 33 experienced harm when there was no evaluation of whether staff was administering the as needed medication to prevent clogging of a feeding tube or whether additional interventions were needed to prevent the resident from being transferred to the local emergency department four times between 08/04/2024 to 09/10/2024. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to thoroughly investigate allegations of abuse or neglect for 3 of 5 sampled residents (Residents 33, 101 and 87) reviewed for abuse. This failure prevented the facility from identifying the extent and nature of the occurrence of abuse/neglect in a timely manner and placed residents at risk for unidentified abuse and/or neglect, and a decreased quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide consistent indwelling urinary catheter (a tube inserted into the bladder to provide urinary drainage) care and management for 3 of 3 sampled residents (Residents 7, 90, and 77) reviewed for urinary catheter. This failed practice placed the residents at increased risk of complications, catheter associated urinary tract infections, including the potential development of sepsis, and a decreased quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine dental care for 1 of 3 sampled residents (Resident 55) when reviewed for dental. This failure placed residents at risk of avoidable dental pain, difficulty eating, unintended weight loss, and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review the facility failed to implement infection control and prevention measures to include transmission based precautions for 3 of 22 sampled residents (Residents 74, 324 and 14), during wound care for 1 of 4 residents (Resident 90) and catheter care for 1 of 3 residents (Resident 7). These failures placed residents at increased risk for healthcare associated infections, related complications and a decreased quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the mechanical lifts (used to help residents move from one surface to another) for 3 of 3 sampled halls (100, 300, and 400 Halls) when reviewed for safety. This failure placed residents at risk for falls, avoidable injury, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the reason for transfer to the hospital to resident or responsible party for 1 of 2 sampled residents (Resident 256) reviewed for hospitalization. This failure placed the resident at risk for not knowing rights regarding transfer and discharge from the facility, and diminished protection from been inappropriately discharged .
Inspectors wroteBased on interview and record review, the facility failed to accurately assess 3 of 22 sample residents (Residents 95, 36 and 90) whose minimum data set (MDS, a required assessment tool) were reviewed. This failure placed the residents at risk of not receiving the care and services required to meet the residents' needs and inaccuracies in their care planning.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bathing/showers and personal hygiene were consistently provided according to the plan of care for 2 of 3 sample residents (Residents 33 and 87), reviewed for Activities of Daily Living (ADL). This failure placed the resident at risk for poor hygiene, decreased self-esteem, and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to monitor and implement interventions for bowel or diabetic care for 2 of 6 sample residents (Residents 38 and 156) reviewed for unnecessary medications and failed to ensure care and monitoring for edema (a condition caused by too much fluid trapped in the body's tissues) or activities of daily living (ADLs) were provided for 2 of 22 sample residents (Resident 156 and 87) when reviewed for showers and skin care. These failures placed the residents at risk for worsening condition, discomfort and a 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 2 sampled residents (Resident 90) 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 ensure residents were provided tracheostomy (an opening surgically created through the neck for breathing) care in accordance with professional standards of practice for 1 of 5 sampled residents (Resident 7) reviewed for respiratory care. This failure placed residents at risk for unmet care needs and potential negative outcomes.
Inspectors wroteResident 456 Resident 456 admitted to the facility on [DATE] with diagnoses that included dementia, chronic obstructive pulmonary disease (a breathing disease), and diabetes. The admission minimum data set (MDS, an assessment tool), dated 09/08/2024, showed Resident 456 was with moderate cognitive impairment. Observation on 09/12/2024 at 12:52 PM showed Resident 456 sitting in wheelchair in the room with a bruise on their forehead. Resident 456 described how they fell when trying to get in bed and hit their head. Review of the EHR showed Resident 456 had fallen on 09/05/2024 and was evaluated in the local emergency room. Continued review showed that Resident 456 was prescribed and administered quetiapine (an antipsychotic medication that affects the mind) in the evening time, with a black box warning that showed an increase in mortality in elderly patients with dementia. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of two errors were made in twenty-five opportunities during a medication administration for 1 of 5 sampled residents (Resident 77) reviewed for medication administration. This placed the residents at risk for receiving medications that were not effective or less effective and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 3 of 3 medication carts (400 front, 400 back, and 300 back) and 2 of 2 medication rooms (300 and 100 halls) when reviewed for medication storage. This failure placed residents at risk for receiving expired medications, and ineffective treatment, and diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal vaccines for 1 of 5 residents (Residents 97) reviewed for vaccinations. This failure placed the resident at a higher risk for contracting pneumococcal infections, related complications, and a decreased quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to post the actual nursing staffing hours daily. This failure prevented the residents, family members, and visitors from exercising their rights to know the actual numbers of available nursing staff in the facility.
Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 6 residents (Resident 1) had Cardiopulmonary Resuscitation (CPR) directives clearly documented and available to inform staff of the resident/resident representative's wishes in the event CPR was needed. The failure to ensure the physician order was updated in the electronic health record (EHR) and the Physician Orders for Life Sustaining Treatment (POLST) form were available placed the resident at risk for not receiving care in accordance with their decision-making if their heart stopped beating or breathing stopped.
Inspectors wroteBased on observation, interview, and record review the facility failed to protect resident's rights to be free from abuse when facility policies and procedures were not implemented for 1 of 8 sampled residents (Resident 1) reviewed for abuse. Resident 1 was assessed for bilateral shoulder subluxation (dislocation) with no investigation conducted to rule out abuse/neglect. This failure placed all residents at risk of abuse, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the reason for transfer/discharge to the hospital, reason why resident cannot be readmitted to the facility, and appeal contact information to the resident or responsible party for 1 of 8 sampled residents (Resident 3) reviewed for facility-initiated discharge. This failure placed residents at risk for diminished protection from being inappropriately discharged .
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement post-op (post-operation) recommendations/orders and to coordinate visits with outside specialty providers, per the health care provider's orders in a timely manner for 1 of 8 sampled residents (Resident 2) reviewed for quality of care. This failure placed residents at risk for delayed healing, health complications, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to provide a written decision for a grievance when requested for 1 of 3 residents (Resident 1) reviewed for grievances. This failure placed residents at risk for unmet care needs and resolution of voiced concerns.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 3 residents (Resident 1). Facility nurses' failure to follow physician orders and only sign for tasks that were completed, placed residents at risk for medication errors, unmet care needs and potential negative outcomes.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control standards were followed related to use of required Personal Protective Equipment (PPE) with residents on Transmission Based Precautions (TBP) for 2 of 6 residents (Resident 2 and 6), cleaning resident equipment and performing hand hygiene between residents for 5 of 6 residents (Resident 2, 3 4, 5 and 7) reviewed for infection control. These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications.
Inspectors wroteBased on interview and record review, the facility failed to address a new skin pressure injury, failed to notify the provider timely and failed to implement wound treatment orders timely for 1 of 5 sampled residents (Resident 1) reviewed for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). Resident 1 experienced harm when they developed a facility acquired pressure ulcer which deteriorated and became infected. This failure placed other residents at risk for development and/or worsening of wounds, infection, and medical complications.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents received medications as ordered and notify the provider and resident/resident representative timely of missed medication for 1 of 7 sampled residents (Resident 1) reviewed for significant medication errors. This failure resulted in harm to Resident 1 who experienced a sudden decline in condition that included the inability to swallow and being in an unresponsive state. This failure prevented Resident 1's decision maker from being fully informed of Resident 1's change in condition prior to a transition onto Hospice Service.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident-to-resident allegation of abuse was reported to the State Agency within 24 hours and failed to log the incident in the facility's reporting log for 2 of 5 sampled residents (Residents 1 & 2) reviewed for abuse and neglect. This failure placed the residents at risk of incidents not being reported and at risk for abuse and neglect.
Inspectors wroteBased on interview and record review, the facility failed to report allegations of neglect to the State Agency within 24 hours and to log the allegations in the facility's reporting log as required for 2 of 3 residents (Residents 1 and 13) when reviewed for abuse/neglect. The failure to report, log and timely investigate allegations of neglect placed residents at risk for ongoing unaddressed neglect, skin breakdown, psychosocial harm, decreased quality of life and other negative healthcare outcomes.
Inspectors wroteBased on observation, interview and record review, the facility failed to complete thorough, timely investigations and timely assess and monitor incidents to rule out abuse or neglect for 4 of 4 residents (Residents 89, 77, 1 and 13) reviewed for Abuse and/or Neglect, and for incidents of falls for 1 of 3 residents (Resident 77) reviewed for Falls. These failures placed residents at risk for unidentified abuse and/or neglect, continued exposure to abuse and/or neglect, unmet needs, injuries, and a decrease quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to accurately document fluids consumed to ensure fluid restrictions (a diet witch limits the amount of daily fluid intake) was implemented per physician orders and/or to monitor, address nutritional needs for 3 of 4 residents (Residents 67, 89, and 94) when reviewed for Nutrition/Hydration and/or Feeding Tubes (a tube to provide liquid food and fluid to the body for nutrition and hydration). These failures placed the resident at risk for medical complications, unmet needs, and a diminished quality of life.
Inspectors wroteResident 22 Review of Resident 22's EHR showed that the resident was admitted to the facility on [DATE] with a diagnosis of major depressive disorder and was taking Duloxetine Hcl (an antidepressant medication) as prescribed by a physician. Review of Resident 22's EHR from January to July 2023 showed one Medication Management Review (MMR) was completed in July 2023. During an interview on 08/07/2023 at 1:15 PM, Staff C, ADNS, stated that an MMR should be completed every month. Additionally, Staff C stated Resident 22's lack of MMR did not meet their expectation. Reference WAC 388-97-1060(3)(k)(i) Resident 2 Review on 08/02/2023 at 4:22 PM of Resident 2's EHR showed a pharmacy review dated 04/21/2023. No other pharmacy reviews were found in the EHR. Review of the facility pharmacy review list showed Resident 2 had a pharmacy review on 06/20/2023 that had recommendations. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure freedom from unnecessary medications for 3 of 5 residents (Residents 67, 2 and 6) reviewed for Unnecessary Medication Use. Failure to provide non-pharmacological interventions (approaches, therapies, or treatments that do not involve drugs) prior to giving as needed pain medications and/or to ensure physician ordered medication parameters were in place and/or followed, placed the residents at risk for side-effects related to the medication, medical complications, and a diminished quality of life.
Inspectors wroteBased on observation and interview, the facility failed to maintain a resident outside food program to ensure resident foods brought from outside the facility were stored according to food safety standards for 3 of 3 resident hallways (100, 300 and 400 Halls) when reviewed for Food Storage. Failure to provide residents with a safe place to store outside food placed residents at risk of consuming contaminated food products, foodborne illness, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to track and trend infections for 3 of 3 months (May, June, and July 2023) reviewed for infection control, to ensure appropriate transmission based precautions were implemented for 3 of 3 residents (Residents 3, 11, and 57) reviewed for transmission based precautions, and to perform wound care following professional standards of infection control for 1 of 2 residents (Resident 1) reviewed for wounds. These failures placed residents, visitors, and staff at an increased risk for infection, related complications, and a decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 2 of 2 residents (Residents 50 and 449) reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents had documented evidence in the medical record that education was provided regarding the benefits and potential side effects of the COVID-19 vaccine for 4 of 5 residents (Residents 73, 88, 454, and 9) reviewed for COVID-19 vaccinations. There was no documented evidence the resident/representative received education and accepted or refused the vaccine. These failures denied the resident/representative of the right to make informed decisions and placed residents at risk for adverse health effects of a communicable disease.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided in a dignified manner which maintained and enhanced quality of life for 1 of 2 residents (Resident 1) reviewed for dignity. This failure placed residents at risk for feelings of embarrassment, disrespect, and decreased self-worth.
Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the reason for transfer/discharge to the resident or responsible party for one of two residents (Residents 23) reviewed for hospitalization. These failures denied the resident or responsible party knowledge of their rights regarding transfer/discharge from the facility and placed residents at risk for diminished protection from being inappropriately discharged .
Inspectors wroteBased on interview and record review, the facility failed to provide a written bed-hold notice at the time of transfer to the hospital for 1 of 2 residents (Residents 23) reviewed for hospitalization. This failure placed the resident at risk for a lack of knowledge regarding their right to hold their bed while in the hospital.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement individualized comprehensive care plans for 2 of 23 residents (Residents 67 and 1) whose care plans were reviewed. Failure to develop and implement care plans that were individualized and accurately reflected resident care needs related to fluid restrictions and turning and repositioning placed residents at risk of unmet care needs and potential negative outcomes.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately reflected resident care needs for 2 of 23 residents (Residents 94 and 1) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and a diminished quality of life.
Inspectors wroteBased on observations, interviews, and record review the facility failed to provide care and services to maintain or improve hearing and communication abilities for 2 of 3 residents (Residents 92 and 1) reviewed for communication. These failures placed the residents at risk for unmet needs and a decreased quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide grooming services for 3 of 5 residents (Residents 48, 92 and 11) when reviewed for Activities of Daily Living. This failure placed residents at risk of feelings of indignity, decreased social interaction, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were safe from falls and/or smoking accidents for 2 of 4 residents (Residents 22 and 86) reviewed for Accident Hazards. This failure placed residents at risk for fall related injury, smoking related injury and a diminished quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided care consistent with professional standards of practice for 1 of 2 residents (Resident 6) reviewed for respiratory care and services. The facility failed to ensure oxygen (O2) was ordered with a dosage, route, or parameters for titration (adjustments). This failure placed the residents at risk for respiratory complications, unmet care needs and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring of orthostatic blood pressure (BP, blood pressure taken while laying, sitting, and standing) and adverse side effect monitoring related to the use of psychotropic (medications that affect the brain) medications occurred for 1 of 5 residents (Resident 22) reviewed for unnecessary medication use. This failure placed residents at risk for adverse side effects and medical complications.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the temperatures were within the proper range for 2 of 3 medication storage refrigerators (300 and 400 hall), that maintenance occurred due to excessive frost/ice build-up for 2 of 3 medication storage refrigerators (100 and 400 hall), and that germicidal/disinfectant cleaning materials were separately stored for 1 of 3 medication storage refrigerators (100 hall) when reviewed for medication storage. In addition, the facility failed to lock 1 of 3 treatment carts (300 hall) and 2 of 3 medication refrigerators (100 and 400 hall) when reviewed for narcotic medication storage. These failures placed residents and staff at potential risk for receiving expired, compromised, or ineffective medications with unknown potency.
Inspectors wroteBased on observation, interview, and record review the facility failed to schedule a dental appointment for 1 of 1 resident (Resident 86) reviewed for dental services. This failure placed the resident at risk for continued dental problems and a decreased quality of life.
Inspectors wroteBased on observation and interview, the facility failed to maintain kitchen equipment in a safe operating condition for 1 of 2 freestanding refrigerators (Refrigerator 1) when reviewed for Kitchen. This failure placed staff at risk of injury, residents at risk of consuming contaminated food products, foodborne illness, and a diminished quality of life.
58 fire safety citations on file: 1 on July 14, 2026, 29 on July 2, 2025, 11 on September 18, 2024, 17 on August 7, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| September 18, 2024 | Fine | $174,304 |
| January 24, 2024 | Fine | $67,511 |
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) | 5.14 | 4.36 | 3.86 |
| Registered nurses | 0.96 | 0.94 | 0.69 |
| All nursing staff on weekends | 4.33 | 3.80 | 3.42 |
| Nurse aides | 3.07 | ||
| Licensed practical nurses | 1.12 | ||
| Nursing staff turnover (share who left in a year) | 49.1% | 45.1% | 45.8% |
| Registered nurse turnover | 57.1% | 45.4% | 42.9% |
| Administrators who left | 1 |
CMS expects 6.27 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 5.47 on weekdays and 4.33 on weekends, 21% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 1.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.54 in April to June 2025 to 5.14 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 | 5.14 | 0.96 | 5.47 | 4.33 | 1.0% | 0 of 90 | 98 |
| Oct to Dec 2025 | 5.10 | 0.90 | 5.40 | 4.33 | 1.0% | 0 of 92 | 100 |
| Jul to Sep 2025 | 5.13 | 1.05 | 5.43 | 4.36 | 0.9% | 0 of 92 | 98 |
| Apr to Jun 2025 | 5.54 | 1.07 | 5.91 | 4.61 | 2.3% | 0 of 91 | 101 |
| 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 | 12.5 | 14.2 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.8 | 1.0 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.6 | 1.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.3 | 2.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.0 | 1.3 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 20.8 | 17.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 7.1 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 17.4 | 15.1 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 11.9 | 19.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 14.1 | 13.4 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.2 | 1.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.5 | 1.5 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Park Rose Care Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (43.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
43.4% this home
No different from 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. 51 eligible stays.
11.0% 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. 48 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
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. 23 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
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. 18 residents counted.
0.0% 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. 27 residents counted.
2.4% 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. 27 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
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. 3 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: BD TACOMA I, LLC. CMS links this home to Regency Pacific Management, a group of 27 nursing homes averaging 3.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Bd Facilities LLC | 5% or greater direct ownership interest | Organization | 100% | 04/01/2017 |
| Beddoe, Marvin | 5% or greater indirect ownership interest | Individual | 99% | 04/01/2017 |
| Regency Pacific Management LLC | Operational/managerial control | Organization | 04/01/2010 | |
| Amadei Gatti, Carla | Operational/managerial control | Individual | 06/03/2025 | |
| Andree, Terri | Operational/managerial control | Individual | 02/19/2018 | |
| Beddoe, Marvin | Operational/managerial control | Individual | 06/01/2009 | |
| Howard, Emma | Operational/managerial control | Individual | 01/06/2025 | |
| Rapp, Andrew | Operational/managerial control | Individual | 03/08/2016 | |
| Bd Facilities LLC | Adp of the SNF | Organization | 04/16/2025 | |
| Omnicare LLC | Adp of the SNF | Organization | 09/01/2013 | |
| Regency Pacific Management LLC | Adp of the SNF | Organization | 08/26/2025 | |
| Amadei Gatti, Carla | Adp of the SNF | Individual | 06/03/2025 | |
| Andree, Terri | Adp of the SNF | Individual | 02/19/2018 | |
| Beddoe, Marvin | Adp of the SNF | Individual | 06/01/2009 | |
| Howard, Emma | Adp of the SNF | Individual | 01/06/2025 | |
| Rapp, Andrew | Adp of the SNF | Individual | 03/08/2016 |
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.
These are the official offices in Washington. NursingHomeClear cannot take or act on complaints.