Your report for Puyallup Nursing and Rehabilitation Center
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- 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 meansHealth inspection ratingCMS stars from the last three on-site inspection cycles3★Above only 45% of peersWA avg2.8★U.S. avg2.8★
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.
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★
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.
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★
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.
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
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
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
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
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 better—No dataWA avg47%RN turnover—
The share of nursing staff who left within the past year, from the same payroll data.
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
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthMar 2023 – Sep 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Sep 15, 2025Cycle 1worst E · no actual harmpayment denial
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsE · patternCorrected Oct 31, 2025
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 31, 2025
- F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Resident RightsE · patternCorrected Oct 31, 2025
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningE · patternCorrected Oct 31, 2025
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceE · patternCorrected Oct 31, 2025
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Oct 31, 2025
- F790Provide routine and 24-hour emergency dental care for each resident.Quality of Life and CareD · isolatedCorrected Oct 31, 2025
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Oct 31, 2025
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Oct 31, 2025
- 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, 2025Cycle 1worst E · no actual harm
- F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.AdministrationE · patternCorrected Jul 18, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jul 18, 2025
Mar 19, 2025Cycle 1worst E · no actual harm
- 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, 2024Cycle 2worst E · no actual harm
- F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Sep 20, 2024
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsE · patternCorrected Sep 20, 2024
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Sep 20, 2024
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceE · patternCorrected Sep 20, 2024
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Sep 20, 2024
- 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
- 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
- F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected Sep 20, 2024
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Sep 20, 2024
- 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
- 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
- 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
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Sep 20, 2024
- 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
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Sep 20, 2024
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Sep 20, 2024
- 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
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Sep 20, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Sep 20, 2024
Aug 13, 2024Cycle 2worst E · no actual harm
- 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
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareE · patternCorrected Sep 16, 2024
Jul 18, 2023Cycle 3worst E · no actual harm
- 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
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Aug 11, 2023
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceE · patternCorrected Aug 11, 2023
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsE · patternCorrected Aug 11, 2023
- 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
- 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
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Aug 11, 2023
- 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
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Aug 11, 2023
- 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
- 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
- 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
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Aug 11, 2023
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareE · patternCorrected Aug 11, 2023
Jun 29, 2023Cycle 3worst G · actual harm$7,443
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Aug 11, 2023
- 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, 2023Cycle 3worst D · no actual harm
- 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 reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined2.60hrs
- Registered nursesRN hours only0.65hrs
- 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 better—WA avg 47%
- RN turnoverRegistered nurses only—Not 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 yearsEnforcement summary
- $7,443In fines
- 1Fine
- 1Payment denial
- $53,236WA avg in fines
Actions on record
- Sep 15, 2025Denial of payment for new admissionsfrom Dec 15, 2025
- Jun 29, 2023Civil money penalty$7,443
Ownership
As filed with CMSStructure
- 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
- James Clay
- Patsy Hand
- Paul Redhead
- James Clay
- Paul Redhead
- Jennifer Mack
Person Organization
Sources & notes
Public data, updated quarterlyData 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.









