Map showing the location of Puyallup Nursing and Rehabilitation Center in PUYALLUP, Washington
516 23RD AVE SE, PUYALLUP, WA, 98372

Overall Score

CMS Five-Star Quality Rating
2/5Below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • WashingtonAbove only 14% of peers192 rated homes · average 3.2★
  • Pierce CountyAbove only 30% of peers21 rated homes · average 3.0★
  • United StatesAbove only 20% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point3★+0.2 vs WA avg
  • StaffingCan add or remove a star1★−2.4 vs WA avg
  • Quality measuresCan add or remove a star4★±0.0 vs WA avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles3★Above only 45% of peersWA avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersWA avg3.4★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above only 29% of peersWA avg4.0★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff2.60hrsLowest tier among peersWA avg4.38Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.65hrsAbove only 25% of peersWA avg0.88Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is betterNo dataWA avg47%RN turnover
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$7,443Above 61% of peersWA avg$53,236Fines · denials1 · 1
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
51citations
8inspection dates
1actual harm (G–I)
0immediate jeopardy (J–L)
Sep 15, 2025most recent

Citations by monthMar 2023 – Sep 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Sep 15, 202510 citationsCycle 1worst E · no actual harmpayment denial
  1. F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsE · patternCorrected Oct 31, 2025
  2. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 31, 2025
  3. F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Resident RightsE · patternCorrected Oct 31, 2025
  4. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningE · patternCorrected Oct 31, 2025
  5. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceE · patternCorrected Oct 31, 2025
  6. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Oct 31, 2025
  7. F790Provide routine and 24-hour emergency dental care for each resident.Quality of Life and CareD · isolatedCorrected Oct 31, 2025
  8. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Oct 31, 2025
  9. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Oct 31, 2025
  10. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsC · widespreadCorrected Oct 31, 2025
Jun 25, 20252 citationsCycle 1worst E · no actual harm
  1. F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.AdministrationE · patternCorrected Jul 18, 2025
  2. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jul 18, 2025
Mar 19, 20251 citationCycle 1worst E · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Apr 15, 2025
Aug 16, 202419 citationsCycle 2worst E · no actual harm
  1. F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Sep 20, 2024
  2. Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Resident RightsE · patternCorrected Sep 20, 2024
  3. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Sep 20, 2024
  4. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceE · patternCorrected Sep 20, 2024
  5. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Sep 20, 2024
  6. F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Resident RightsD · isolatedCorrected Sep 20, 2024
  7. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsE · patternCorrected Sep 20, 2024
  8. F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected Sep 20, 2024
  9. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Sep 20, 2024
  10. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningE · patternCorrected Sep 20, 2024
  11. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Sep 20, 2024
  12. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Sep 20, 2024
  13. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Sep 20, 2024
  14. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Sep 20, 2024
  15. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Sep 20, 2024
  16. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Sep 20, 2024
  17. F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceE · patternCorrected Sep 20, 2024
  18. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Sep 20, 2024
  19. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Sep 20, 2024
Aug 13, 20242 citationsCycle 2worst E · no actual harm
  1. F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Resident Assessment and Care PlanningE · patternCorrected Sep 16, 2024
  2. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareE · patternCorrected Sep 16, 2024
Jul 18, 202314 citationsCycle 3worst E · no actual harm
  1. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Aug 11, 2023
  2. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Aug 11, 2023
  3. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceE · patternCorrected Aug 11, 2023
  4. Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Resident RightsE · patternCorrected Aug 11, 2023
  5. F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Infection ControlE · patternCorrected Aug 11, 2023
  6. F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceE · patternCorrected Aug 11, 2023
  7. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Aug 11, 2023
  8. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsE · patternCorrected Aug 11, 2023
  9. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Aug 11, 2023
  10. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Aug 11, 2023
  11. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Aug 11, 2023
  12. F688Provide 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.Quality of Life and CareE · patternCorrected Aug 11, 2023
  13. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Aug 11, 2023
  14. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareE · patternCorrected Aug 11, 2023
Jun 29, 20232 citationsCycle 3worst G · actual harm$7,443
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Aug 11, 2023
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Aug 11, 2023
Mar 27, 20231 citationCycle 3worst D · no actual harm
  1. F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Resident RightsD · isolatedCorrected Apr 28, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined2.60hrsLowest tier among peers−1.78 vs WA avg
  • Registered nursesRN hours only0.65hrsAbove only 25% of peers−0.23 vs WA avg
  • Licensed practical nursesLPN hours0.44hrs
  • Nurse aidesCNA hours1.51hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.30hrs
  • Washington average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is betterWA avg 47%
  • RN turnoverRegistered nurses onlyNot ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy96 certified beds · ~72 residents a day75%Above only 41% of peersWA avg 76%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $7,443In fines
  • 1Fine
  • 1Payment denial
  • $53,236WA avg in fines
Above 61% of peersFewer fines than 61% of rated homes in Washington

Actions on record

  1. Sep 15, 2025Denial of payment for new admissionsfrom Dec 15, 2025
  2. Jun 29, 2023Civil money penalty$7,443

Ownership

As filed with CMS

Structure

Ownership type
For profit - Corporation
Chain
Regency Pacific Management27 facilities in the chain3.7★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • James Clay
  • Patsy Hand
  • Paul Redhead
Corporate officers
  • James Clay
  • Paul Redhead
Managing employees
  • Jennifer Mack

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 505211 · 516 23RD AVE SE, PUYALLUP, WA, 98372.
  • Percentiles compare this facility with every rated nursing home in Washington and Pierce County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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