Tacoma Nursing and Rehabilitation: Menu Failures - WA
Between those two visits, inspectors documented a pattern of substitutions, shortcuts, and menu departures that the facility's own administrator said did not meet expectations.
On the first inspection day, Staff M, the dietary manager, was serving the lunch rice with a gray-handled scoop and the vegetable medley with a green-handled scoop. Neither of those were the problem. The carrots she was offering as an alternative to the vegetable medley were being scooped with the unmeasured silver spoon — and carrots weren't listed on the menu as an alternative at all.
The dessert that afternoon was supposed to be chocolate cake with peanut butter. What residents received instead, at 12:29 p.m., was cinnamon apples — the dessert that had been served the previous day at lunch.
Residents on soft and bite-size, minced, and pureed diets were supposed to receive altered-texture rice. There wasn't any. Staff M told inspectors that residents on those diets were served mashed potatoes instead. The menu said nothing about mashed potatoes.
When inspectors returned on June 22, the problems were the same. The lunch menu called for teriyaki pot roast, snap peas, steamed rice, a dinner roll, and peach shortcake. At 11:49 a.m., staff were serving the rice and snap peas with unmeasured silver slotted spoons. Staff M confirmed it. She also confirmed, again, that no altered-texture rice had been prepared for residents who needed it. Mashed potatoes again.
At 11:57 a.m., inspectors watched staff prepare two cheeseburgers using slices of white bread in place of hamburger buns.
Staff M's explanation for the spoons was direct: she said the unmeasured silver slotted spoons were for cooking, not serving, and that the facility ensured correct portion sizes by using measured scoops. She said the menu specified the correct amounts. She also said, without apparent contradiction, that the facility did not follow the menu when it called for altered-texture rice and gave mashed potatoes instead.
Staff A, the administrator, told inspectors that kitchen staff ensured portion sizes by following menu-specified portions and using measured spoons. She said the observations of staff using unmeasured or incorrectly measured spoons "did not meet expectations."
The inspection report classified the harm level as minimal, with potential for actual harm. Inspectors noted the failures placed residents at risk of receiving reduced portions, inadequate nutrition, avoidable weight loss, and a diminished quality of life. The findings covered many residents.
What the report captures is a kitchen operating on two separate tracks: what the menu said would be served, and what was actually put in front of residents. The dietary manager knew the menu specified altered-texture rice. She substituted mashed potatoes anyway, on both days inspectors observed, and described it as standard practice. The administrator described the same kitchen as one that followed menu portions and used measured spoons.
For residents on modified diets, the distinction between rice and mashed potatoes is not interchangeable preference. Altered textures are prescribed. The residents who needed that preparation didn't get it, and the staff member responsible said plainly that the facility didn't follow the menu in those cases.
Nobody in the kitchen on either day reached for a measured spoon for the rice.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tacoma Nursing and Rehabilitation Center from 2026-06-22 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
TACOMA NURSING AND REHABILITATION CENTER in TACOMA, WA was cited for violations during a health inspection on June 22, 2026.
Neither of those were the problem.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.