Regency Coupeville Rehab And Nursing Center
REGENCY COUPEVILLE REHAB AND NURSING CENTER in COUPEVILLE, WA — inspection on February 26, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Findings included.
Review of the facility's policy, titled, Interdisciplinary Care Conference, dated 3/2024 and revised on 12/16, documented an interdisciplinary care conference is completed upon the resident's admission to the facility, quarterly, and following a change in condition.
The resident and/or the resident representative will be invited to the care conference. Resident 1 was admitted to the facility on [DATE] with a diagnosis to include dementia with anxiety.
Review of Resident 1's electronic medical record (EMR) documented a care plan conference (CPC), dated 07/14/2025, was held.
There were no other CPCs found in Resident 1's EMR.
During a telephone interview on 02/12/2026 at 11:00 AM, Collateral Contact 1 (CC 1) stated they have only attended one CPC since Resident 1 was admitted to the facility. CC 1 stated there had been a CPC set up within the past month, and something had come up at the last minute and was not able to attend and requested for the meeting to be rescheduled. CC 1 stated they would like to be involved in Resident 1's care. In an interview on 02/26/2026 at 2:34 PM, Staff J, Social Services, stated CPCs were completed within the residents first week of admission, and quarterly CPCs were set up in accordance with the residents scheduled Minimum Data Set (MDS - an assessment tool) assessment.
Staff J was asked about Resident 1 CPCs.
There was one documented CPC held on 07/14/2025 at 2:00 PM located in Resident 1's medical record.
Staff J searched through Resident 1's EMR and did not find any additional CPCs.
Staff J stated the facility was working on scheduling a CPC with Resident 1 and CC 1.
Reference WAC 388-97-0200(3) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
505309 02/26/2026
Regency Coupeville Rehab and Nursing Center 311 Northeast 3rd Street Coupeville, WA 98239
Review of Resident 3's nursing progress notes, dated 12/01/2025 to
02/26/2026 at 1:47 PM, Staff F, NAC, stated residents were showered twice a week.
When a resident refused their shower, they would attempt to offer it again before their next scheduled shower day.
Staff F stated they document in PCC when they gave a resident a shower.
Staff F stated if a resident refused a shower they would inform the nurse on duty. In an interview on 02/26/2026 at 1:58 PM, Staff H, NAC, stated the residents were scheduled to receive two showers a week. If a resident refused a shower, they would reapproach two times, and if they continued to refuse would document the refusal in PCC and notify the nurse.
Staff H stated they would try to offer the resident a shower later in the week.
Review of an email communication on 02/26/2026 at 3:59 PM, Staff C, Registered Nurse (RN)/Regional Director of Clinical Operations, documented the facility does not have a resident shower policy.
Reference WAC 388-97-0180(2)
505309 02/26/2026
Regency Coupeville Rehab and Nursing Center 311 Northeast 3rd Street Coupeville, WA 98239
Review of Resident 1's Minimum Data Set (MDS - an assessment tool) assessment, dated 12/30/2025, documented the resident had severe cognitive impairment.During a telephone interview on 02/12/2026 at 11:00 AM, Collateral Contact 1 (CC 1), Resident 1's responsible party, stated they were not kept informed of when Resident 1 had any changes in their medications.
Review of a physician order, dated 01/21/2026, documented to increase Resident 1's acetaminophen (a pain reliver) to two tablets every 12 hours and start a lidocaine external patch to their lower back daily and removed per schedule for back pain.
Review of Resident 1's electronic medical record showed CC1 had not been notified of the resident's back pain or the medication change.On 02/26/2026 at 4:52 PM, Staff B, Chief Operating Officer, Staff C, Registered Nurse (RN)/Regional Director of Clinical Operations, and Staff K, RN/Corporate nurse, were asked if residents responsible party were notified when there were medication changes.
Staff C stated yes.
The staff were notified that CC 1 had not been notified of Resident 1's 01/21/2026 medication changes.
Reference WAC 388-97-0320(1)(c)
505309 02/26/2026
Regency Coupeville Rehab and Nursing Center 311 Northeast 3rd Street Coupeville, WA 98239
Findings included .
Review of the Level 1 PASRR document, revised 06/2025, documented if the resident had an ID or RC, the form was to be forwarded to the Regional DDA ID/RC PASRR team, and follow up by the DDA Administration was required before the resident could be admitted to a nursing facility.Resident 2 was admitted to the facility on [DATE] with diagnoses to include intellectual disabilities, and disorders of psychological development.Review of Resident 2's Level 1 PASRR, dated 02/09/2026, documented they had an ID and were required to forward the form to the Regional DDA ID/RC PASRR team before the resident could be admitted to a nursing facility.Review of Resident 2's Electronic Medical Record (EMR) showed no documentation the Regional DDA ID/RC PASRR team had been contacted prior to their admission to the facility.In an interview on 02/26/2026 at 2:33 PM, Staff J, Social Services Director (SSD) stated they were unaware the Level I PASRR was required to be forwarded to the Regional DDA ID/RC PASRR team prior to admission to the facility.
Staff J stated Staff I, Admissions, were the ones who reviewed PASRR information before a resident was admitted .
Staff J stated they did not see a resident's PASRR until after they had been admitted to the facility, after it was scanned into the EMR by medical records.In an interview on 02/26/2026 at 3:07 PM, Staff I, Admissions, stated they were responsible to review the Level 1 PASRR forms prior to admission to the facility and were unaware that Resident 2's PASRR was required to be forwarded to the Regional DDA ID/RC PASRR team for review and determination for admission to the facility related to their diagnosis of an intellectual disability.
Reference WAC: 388-97-1915(1)(2)(a-c)
505309 02/26/2026
Regency Coupeville Rehab and Nursing Center 311 Northeast 3rd Street Coupeville, WA 98239
Review of Resident 10's EMR documented they had an interdisciplinary care conference on 2/17/2026, and the documentation was not completed by Staff J, SSD, until 02/22/2026. <RESIDENT 11>Resident 11 was admitted to the facility on [DATE].
Review of Resident 11's EMR documented that they had an interdisciplinary care conference on 12/17/2025, and the documentation was not completed by Staff J, SSD, until 12/26/2025.
On 02/26/2026 at 4:52 PM, an interview was conducted with Staff B, Chief Operating Officer, Staff C, Registered Nurse (RN)/Regional Director of Clinical Operations, and Staff K, RN/Corporate Nurse.
Staff B stated a Care Plan Conference User-Defined Assessment (UDA) form may be initiated prior to the scheduled CPC. On the day the CPC was held the expectation was it was completed/locked within a day.
When asked when the NAC should complete their documentation in PCC stated by the end of their shift.
The staff were made aware of the incomplete NAC documentation found in PCC.
Reference WAC 388-97-1720 (a)(i)(ii),(4)(a)
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.