Washington ›Pt Orchard

Washington Veteran Home-Retsil

1141 Beach Drive, Pt Orchard, WA 98366 · Kitsap County · 240 certified beds · avg 232 residents/day · certified since Mar 1, 2007

3/5
Health inspection rating (on-site)
1
Serious findings on record
$23,920
Fines, last 3 years
4.18
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Jul 2, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jul 11, 2025 (Deficient, Provider has date of correction)

All citations in the current public record (59)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
May 11, 2026E · Potential for harm, repeatedThe facility did not honor residents' right to manage their own money and financial affairs.
May 11, 2026E · Potential for harm, repeatedThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
May 11, 2026E · Potential for harm, repeatedThe facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
May 11, 2026E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
May 11, 2026E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 11, 2026D · Potential for harm, one-offThe facility did not keep residents' personal and medical information private and confidential.
May 11, 2026D · Potential for harm, one-offThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
May 11, 2026D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
May 11, 2026D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
May 11, 2026D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
May 11, 2026D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
May 11, 2026D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
May 11, 2026D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
May 11, 2026D · Potential for harm, one-offThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
May 11, 2026D · Potential for harm, one-offThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Apr 7, 2026D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jul 11, 2025D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Jul 11, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jul 2, 2025▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Apr 28, 2025E · Potential for harm, repeatedThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Apr 28, 2025E · Potential for harm, repeatedThe facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Apr 28, 2025E · Potential for harm, repeatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Apr 28, 2025E · Potential for harm, repeatedThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Apr 28, 2025D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Apr 28, 2025D · Potential for harm, one-offThe facility did not properly notify residents about the balance of money it holds for them, or failed to return those funds when a resident was discharged, evicted, or died.
Apr 28, 2025D · Potential for harm, one-offThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
Apr 28, 2025D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Apr 28, 2025D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Apr 28, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Apr 28, 2025D · Potential for harm, one-offThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Apr 28, 2025D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Apr 28, 2025D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Apr 28, 2025D · Potential for harm, one-offThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 28, 2025D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Mar 14, 2025E · Potential for harm, repeatedThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Mar 14, 2025D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Dec 20, 2024D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Dec 20, 2024D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
Jul 12, 2024D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Apr 22, 2024F · Potential for harm, facility-wideThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Apr 22, 2024E · Potential for harm, repeatedThe facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time.
Apr 22, 2024E · Potential for harm, repeatedThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Apr 22, 2024E · Potential for harm, repeatedThe facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Apr 22, 2024E · Potential for harm, repeatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Apr 22, 2024E · Potential for harm, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Apr 22, 2024E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Apr 22, 2024E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Apr 22, 2024E · Potential for harm, repeatedThe facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life.
Apr 22, 2024D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Apr 22, 2024D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Apr 22, 2024D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Apr 22, 2024D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Apr 22, 2024D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Apr 22, 2024D · Potential for harm, one-offThe facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them.
Apr 22, 2024D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Mar 8, 2024D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Nov 9, 2023D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Nov 9, 2023D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Sep 14, 2023D · Potential for harm, one-offThe facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (15 → 15).

YearCitationsSerious (G–L)Worst severity that year
202330D
2024200F
2025201G ▲
2026160E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $23,920, plus 1 Medicare payment denial period.

DateTypeAmount / length
Jul 2, 2025Fine$23,920
Mar 14, 2025Payment Denial3 days from Jun 14, 2025

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityWashington avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)4.184.243.95top 37% in Washington; top 33% in the U.S.
Registered Nurse hours0.980.910.69top 33% in Washington; top 17% in the U.S.
Weekend total nurse staffing3.823.693.50top 27% in Washington; top 28% in the U.S.
Weekend RN hours (not acuity-adjusted)0.720.670.48top 37% in Washington; top 15% in the U.S.
Total nursing staff turnover (%)45.145.145.8bottom 45% in Washington; bottom 50% in the U.S.
RN turnover (%)26.145.442.9top 15% in Washington; top 23% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.88, RN 0.91, weekend 3.55. Staffing rating: 5/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5

Who owns this facility

Government - State

Owner / managerTypeRoleStakeSince
Washington State Department of VeteOrganization5% or Greater Direct Ownership Interest100%03/01/2007
Fang, AaronIndividualOperational/Managerial ControlNOT APPLICABLE05/07/2024
Fang, AaronIndividualADP of the SNFNOT APPLICABLE05/07/2024
Gilbert, SolomonIndividualManaging Control - Governing BodyNOT APPLICABLE05/22/2023
Lysobey, MatthewIndividualOperational/Managerial ControlNOT APPLICABLE03/20/2023
Lysobey, MatthewIndividualADP of the SNFNOT APPLICABLE11/24/2025
Murray, DanielIndividualManaging Control - Governing BodyNOT APPLICABLE11/16/2021
Puente, DavidIndividualManaging Control - Governing BodyNOT APPLICABLE02/01/2023
Puente, DavidIndividualOperational/Managerial ControlNOT APPLICABLE02/01/2023
Westhoff, TerranceIndividualOperational/Managerial ControlNOT APPLICABLE09/01/2020

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Port Washington Post Acute2.6 miBremerton, WA★☆☆☆☆1/5
Belmont Terrace2.7 miBremerton, WA★★★☆☆2/5
Life Care Center of Port Orchard2.7 miPort Orchard, WA★★★★★4/5
Avamere Rehabilitation at Ridgemont2.8 miPort Orchard, WA★★★★☆4/5
Bremerton Trails Post Acute2.8 miBremerton, WA★☆☆☆☆1/5SFF
Bainbridge Island Health & Rehab Center7.2 miBainbridge Island, WA★★★★★5/5
Northwoods Lodge9.4 miSilverdale, WA★★★★★4/5
Avamere Rehabilitation at Park West10.7 miSeattle, WA★★☆☆☆2/5
Providence Mount St Vincent10.8 miSeattle, WA★★★☆☆2/5
Avamere Rehabilitation of Burien12.8 miBurien, WA★★☆☆☆2/5
Heron's Key12.9 miGig Harbor, WA★★★★★5/5
Martha and Mary Health Service13.3 miPoulsbo, WA★★★★☆3/5

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Facility data as of CMS processing date 2026-08-01. CCN 505517.