Tacoma Nursing And Rehabilitation Center
TACOMA NURSING AND REHABILITATION CENTER in TACOMA, WA — inspection on June 22, 2026.
Found 6 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
Review of the focused care plan for COPD showed Resident 34 was on O2 therapy; however, it was
During an interview on 06/18/2026 at 10:33 AM, Staff G, RCM/LPN, stated Resident 34 was on O2 therapy; however, the care plan was not initiated until 06/15/2026 and this did not meet their expectations.
Staff G stated O2 therapy care plan should have been initiated when Resident 34 was readmitted from the hospital on [DATE].
During an interview on 06/18/2026 at 10:59 AM, Staff B, DNS, stated Resident 34's care plan for O2 therapy did not meet their expectations. Resident 9 Review of the EHR showed Resident 9 admitted to the facility on [DATE] with diagnoses of pneumonia (a lung infection), diabetes, and congestive heart failure (CHF, when the heart can no longer pump enough blood).
The resident was able to make needs known.
Review of the EHR showed Resident 9 had a provider order for oxygen at two liters per minute with a start date of 11/19/2025.
Review of the minimum data set assessment (MDS) showed Resident 9 was receiving oxygen during their stay.
Review of the current plan of care on 06/17/2026 for Resident 9 showed oxygen was not included.
During an interview on 06/18/2026 at 10:28 AM, Staff C, RCM/LPN, stated Resident 9 should have had a care plan in place for the use of oxygen.
During an interview on 06/18/2026 at 10:35 AM, Staff B, DNS, stated it was their expectation that residents with CHF who received oxygen had it included in their comprehensive care plan and this did not happen for Resident 9 but should have.
Reference WAC 388-97-1020(1)(2)(a)(b)
505154 06/22/2026
Tacoma Nursing and Rehabilitation Center 2102 South 96th Street Tacoma, WA 98444
Review of the EHR showed Resident 47 admitted to the facility on [DATE] with diagnoses to include dementia (a group of symptoms affecting memory).
The resident was able to make needs known.
During an interview and observation on 06/16/2026 at 1:40 PM, Resident 47 stated I can't hear you and smiled.
There was no hearing aids noted in the resident's ears.
During an interview and observation on 06/17/2026 at 11:28 AM, Resident 47 sat in their room watching the television, and no hearing aids were observed in the resident's ears.
Review of the current plan of care on 6/17/2026 showed interventions for staff to place hearing aids in the morning and remove them to be charged in the evening.
Review of the provider orders showed licensed nurses were to apply the hearing aids in the morning and remove them to charge at night, with a start date of 03/13/2024.
Observation on 06/18/2026 at 9:09 AM showed Resident 47 with no hearing aid in place.
During an interview on 06/18/2026 at 9:09 AM, Resident 47's roommate (Resident 78) stated [Resident 47] does not wear the hearing aids.
They do not help. I think their son took them home a while ago.
Review of the EHR showed staff documented in the medication administration record (MAR) from 06/01/2026 through 06/18/2026 that Resident 47 had their hearing aids placed in the mornings and removed to charge in the evening.
During an interview on 06/18/2026 at 9:31 AM, Staff D, LPN, stated Resident 47's hearing aids did not work and maybe their son took them.
Staff D stated they use a whiteboard to communicate.
During an interview on 06/18/2026 at 9:34 AM, Staff E, CNA, stated Resident 47 did not like wearing the hearing aids.
During an interview on 06/18/2026 at 9:37 AM, Staff B, DNS, stated this did not meet their expectations for Resident 47.
Staff B stated Resident 47 did not wear the hearing aids and their son took them home because they do not help.
Reference WAC 388-97-1620(2)(b)(i)(ii)(6)(b)(i)
505154 06/22/2026
Tacoma Nursing and Rehabilitation Center 2102 South 96th Street Tacoma, WA 98444
During an interview and observation on 06/16/2026 at 1:03 PM, Resident 114 stated they would like to have dentures because they had no teeth and staff were aware; however, they still had no dentures. Resident 114 had no upper or lower teeth and no visible dentures in their room.
Review of the annual minimum data set assessment (MDS) dated [DATE] showed Resident 114 had no natural teeth or tooth fragments.
Review of Resident 114's EHR showed a focused care plan for activities of daily living self-care performance deficit, initiated on 09/27/2023, with an intervention for Oral Care: The resident has missing teeth.
Upper/lower dentures not with [Resident 114].
The resident requires oral inspection.
Report changes to the nurse.
Set up assist with oral cavity cares, initiated on 09/27/2023 and revised on 06/14/2024. It showed a focused care plan for potential oral/dental health problems related to edentulous [no natural teeth].
Resident is waiting for dentures initiated on 10/05/2023 and revised on 05/29/2026.
Review of Resident 114's dental/dentures visit/exam form dated 05/22/2024 showed the provider recommended new upper and lower dentures. It showed handwritten on the form, Pt. [patient] said dentures lost a few weeks ago. Pt. would like new dentures.
Review of Resident 114's dental/dentures visit/exam forms, dated 09/16/2024 and 01/23/2025, showed the provider recommended new upper and lower dentures.
Review of Resident 114's Washington State Heath Care Authority Denture/Partial Appliance Request For Skilled Nursing Facility Client, form dated 01/29/2025 showed it was signed by the provider on 02/14/2025 and had handwritten on the form Emailed 2/17/25 @ 10:06 AM.
Review of Resident 114's dental/dentures visit/exam forms dated 06/09/2025 and 03/16/2026 showed the provider recommended new upper and lower dentures.
During an interview on 06/18/2026 at 12:40 PM, Staff G, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated they were not sure if Resident 114's denture request had been denied or not.
Staff G stated that Staff Q, Central Supply/Transportation, would work with the denturist and the authorization process.
Staff G stated that they should have been notified if the request had been denied and they had not been informed.
Staff G stated on 05/05/2026 there was another request for Resident 114's dentures completed and it was emailed on 05/06/2026; however, this issue should have been addressed a lot sooner and this did not meet expectations.
During an interview on 06/18/2026 at 1:06 PM, Staff Q, Central Supply/Transportation, stated they were not aware of Resident 114's denture request had been denied but could find out.
Staff Q then called and spoke to the dental operations manager.
Staff Q stated the dental operations manager stated that Resident 114's January 2025 denture request was denied due to needing additional information.
Staff Q stated that Resident 114's denture request should have been addressed sooner, and this did not meet expectations.
During an interview on 06/18/2026 at 1:57 PM, Staff A, Administrator, stated Resident 114's request for dentures should have been addressed sooner and this did not meet their expectations.
Reference WAC 388-97-1060(1)
505154 06/22/2026
Tacoma Nursing and Rehabilitation Center 2102 South 96th Street Tacoma, WA 98444
Review of the menu for 06/17/2026 lunch showed a half cup of vegetable medley, a half cup of rice, and did not show carrots included as an alternate.
Review showed that residents with soft and bite size, minced, and pureed diets received altered rice.
Review showed chocolate cake with peanut butter was to be served for dessert.
Observation on 06/17/2026 at 12:29 PM showed the facility served cinnamon apples (the previous day's lunch dessert) for dessert.
Observation and interview on 06/17/2026 at 12:32 PM showed there was no rice prepared for residents with soft and bite size, minced, and pureed diets.
Staff M, Dietary Manager, stated residents with soft and bite size, minced, and pureed diets were served mashed potatoes instead of rice.
Review of the menu for 06/22/2026 lunch showed teriyaki pot roast, snap peas, steamed rice, dinner roll, and peach short cake was to be served.
Observation on 06/22/2026 at 11:49 AM showed the rice and snap peas were being served using unmeasured silver slotted spoons.
During an interview on 06/22/2026 at 11:50 AM, Staff M, Dietary Manager, stated unmeasured silver slotted spoons were being used to serve rice and snap peas.
Staff M stated no altered texture rice was prepared and mashed potatoes were being served in its place.
Observation on 06/22/2026 at 11:57 AM showed facility staff prepared an order of two cheeseburgers that used slices of white bread in lieu of hamburger buns.
During an interview on 06/22/2026 at 12:46 PM, Staff M, Dietary Manager, stated the facility ensured portion sizes were correct by using measured scoops when serving, and the unmeasured silver slotted spoons were for cooking.
Staff M stated the menu would specify the correct amount to be provided.
Staff M stated the facility did not follow the menu when it specified altered textured rice and instead would provide mashed potatoes.
During an interview on 06/22/2026 at 1:57 PM, Staff A, Administrator, stated kitchen staff ensured portions sizes were correct by following the menu specified portions and using measured spoons and the observations of staff using unmeasured or incorrect measured spoons did not meet expectations.
Reference WAC 388-97-1160(1)(a)(b), -1120(3)(c)(4) 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
505154 06/22/2026
Tacoma Nursing and Rehabilitation Center 2102 South 96th Street Tacoma, WA 98444
Observation on 06/17/2026 at 2:46 PM showed the dry storage can rack contained two dented cans of mandarin oranges.
During an interview on 06/22/2026 at 12:46 PM, Staff M, Dietary Manager, stated the facility put dented cans of food product in a separate area to be thrown away.
Staff M stated dented cans would be used if they were not too damaged, which was when a can was dented in too far compared to a minor dent.
Staff M stated the trash can at the handwashing sink could be used to dispose of used paper towels if the lid to the can was slid over a little bit, and, if it was not, staff could use a paper towel to slide it open.
Staff M stated the facility's freezer had not been cooling correctly on 06/17/2026.
During an interview on 06/22/2026 at 1:57 PM, Staff A, Administrator, stated the observation of stored and used dented cans did not meet expectations.
Staff A stated the kitchen's handwashing sink should have a foot operated trashcan to avoid cross contamination when throwing away paper towels.
Reference WAC 388-97-1100(3), -2980
505154 06/22/2026
Tacoma Nursing and Rehabilitation Center 2102 South 96th Street Tacoma, WA 98444
Findings included.
Review of the electronic health record (EHR) showed Resident 12 was readmitted to the facility on [DATE] with diagnoses to include heart failure, end of life care (hospice), and compression fracture in the lumbar (low back) area. Resident 12 was able to communicate needs. <Enhanced Barrier Precautions>
Review of the care plan, initiated on 01/19/2026, showed Resident 12 was to have EBP (staff to wear gown and gloves [PPE, personal protective equipment] when completing high contact care) related to the use of a catheter.
Observation on 06/17/2026 at 01:26 PM showed Staff H, Certified Nursing Assistant (CNA), answered Resident 12's call light and provided incontinence care without wearing an isolation gown, only gloves.
During the care, Staff H touched the bed linen, privacy curtain, and Resident 12's gown with their uniform. Resident 12 was laying on full size bed and Staff H was leaning on to the bed to reach Resident 12's body. <Hand Hygiene> Observation on 06/17/2026 at 1:28 PM showed Staff H, CNA, removed the front part of Resident 12's incontinent brief and wiped loose stools with wipes, then Staff H touched the privacy curtain, bed linens, and pillow that was on the chair next to bed with the soiled gloves.
Staff H did not change gloves or perform hand hygiene after touching stools and wiping.
A second unidentified CNA came into the room with gown and gloves and assisted Staff H with turning Resident 12 and continued with wiping loose stools from the back.
The second CNA changed gloves and did not perform hand hygiene.
Observation on 06/17/2026 at 1:40 PM showed Staff J, Registered Nurse (RN), entered Resident 12's room and applied ointment.
Staff J stated Staff H should not have provided care without proper PPE and hand hygiene.
During an interview on 06/22/2026 at 12:43 PM, Staff B, Director of Nursing Services, stated the staff were to perform hand hygiene before putting on gloves when changing gloves and after using gloves.
Staff B stated staff not following EBP and lack of hand hygiene did not meet expectations.
Reference WAC 388-97 -1320 (1)(c) (2)(a)
Frequently Asked Questions
More Reports
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.