1141 Beach Drive, Pt Orchard, WA 98366 (opens Google Maps) · Kitsap County · (360) 895-4700· 240 certified beds · avg 232 residents/day · certified since Mar 1, 2007 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
New to these records? How to read an inspection report →
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5 · how star ratings work →
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 quality measures from resident assessments and claims.
▲ Actual harm, isolated · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Jul 11, 2025 (Deficient, Provider has date of correction)
Showing the latest 3 of 59 inspection findings. Open the full record below to read every finding.
The facility did not honor residents' right to manage their own money and financial affairs. F-0567
The 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. F-0578
The 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. F-0605
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 11, 2026 | E · Potential for more than minimal harm, pattern | The facility did not honor residents' right to manage their own money and financial affairs. · F-0567 |
| May 11, 2026 | E · Potential for more than minimal harm, pattern | The 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. · F-0578 |
| May 11, 2026 | E · Potential for more than minimal harm, pattern | The 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. · F-0605 |
| May 11, 2026 | E · Potential for more than minimal harm, pattern | The 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. · F-0725 |
| May 11, 2026 | E · Potential for more than minimal harm, pattern | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The facility did not keep residents' personal and medical information private and confidential. · F-0583 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The 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. · F-0585 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · F-0609 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The 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. · F-0656 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · F-0658 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The 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. · F-0677 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The 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. · F-0688 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The 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. · F-0757 |
| Apr 7, 2026 | D · Potential for more than minimal harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689 |
| Jul 11, 2025 | D · Potential for more than minimal harm, isolated | The 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 · F-0610 |
| Jul 11, 2025 | D · Potential for more than minimal harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689 |
| Jul 2, 2025 | ▲ G · Actual harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689 |
| Apr 28, 2025 | E · Potential for more than minimal harm, pattern | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641 |
| Apr 28, 2025 | E · Potential for more than minimal harm, pattern | The 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. · F-0645 |
| Apr 28, 2025 | E · Potential for more than minimal harm, pattern | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · F-0658 |
| Apr 28, 2025 | E · Potential for more than minimal harm, pattern | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. · F-0883 |
| Apr 28, 2025 | D · Potential for more than minimal harm, isolated | The 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. · F-0550 |
| Apr 28, 2025 | D · Potential for more than minimal harm, isolated | The 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. · F-0569 |
| Apr 28, 2025 | D · Potential for more than minimal harm, isolated | The 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. · F-0585 |
| Apr 28, 2025 | D · Potential for more than minimal harm, isolated | The 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. · F-0657 |
| Apr 28, 2025 | D · Potential for more than minimal harm, isolated | The 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. · F-0677 |
| Apr 28, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684 |
| Apr 28, 2025 | D · Potential for more than minimal harm, isolated | The 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. · F-0757 |
| Apr 28, 2025 | D · Potential for more than minimal harm, isolated | The 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. · F-0758 |
| Apr 28, 2025 | D · Potential for more than minimal harm, isolated | The 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. · F-0761 |
| Apr 28, 2025 | D · Potential for more than minimal harm, isolated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Apr 28, 2025 | D · Potential for more than minimal harm, isolated | The 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. · F-0880 |
| Mar 14, 2025 | E · Potential for more than minimal harm, pattern | The 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 · F-0609 |
| Mar 14, 2025 | D · Potential for more than minimal harm, isolated | The 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 · F-0610 |
| Dec 20, 2024 | D · Potential for more than minimal harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689 |
| Dec 20, 2024 | D · Potential for more than minimal harm, isolated | The 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 · F-0690 |
| Jul 12, 2024 | D · Potential for more than minimal harm, isolated | The 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 · F-0677 |
| Apr 22, 2024 | F · Potential for more than minimal harm, widespread | The 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. · F-0725 |
| Apr 22, 2024 | E · Potential for more than minimal harm, pattern | The 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. · F-0561 |
| Apr 22, 2024 | E · Potential for more than minimal harm, pattern | The 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 · F-0610 |
| Apr 22, 2024 | E · Potential for more than minimal harm, pattern | The 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. · F-0676 |
| Apr 22, 2024 | E · Potential for more than minimal harm, pattern | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684 |
| Apr 22, 2024 | E · Potential for more than minimal harm, pattern | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689 |
| Apr 22, 2024 | E · Potential for more than minimal harm, pattern | The 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. · F-0761 |
| Apr 22, 2024 | E · Potential for more than minimal harm, pattern | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · F-0804 |
| Apr 22, 2024 | E · Potential for more than minimal harm, pattern | The 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. · F-0849 |
| Apr 22, 2024 | D · Potential for more than minimal harm, isolated | The 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. · F-0550 |
| Apr 22, 2024 | D · Potential for more than minimal harm, isolated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641 |
| Apr 22, 2024 | D · Potential for more than minimal harm, isolated | The 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. · F-0657 |
| Apr 22, 2024 | D · Potential for more than minimal harm, isolated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · F-0658 |
| Apr 22, 2024 | D · Potential for more than minimal harm, isolated | The 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. · F-0690 |
| Apr 22, 2024 | D · Potential for more than minimal harm, isolated | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · F-0694 |
| Apr 22, 2024 | D · Potential for more than minimal harm, isolated | The 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. · F-0758 |
| Mar 8, 2024 | D · Potential for more than minimal harm, isolated | The 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 · F-0658 |
| Nov 9, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584 |
| Nov 9, 2023 | D · Potential for more than minimal harm, isolated | The 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 · F-0677 |
| Sep 14, 2023 | D · Potential for more than minimal harm, isolated | The 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 · F-0744 |
Citations from standard inspections stayed about the same across the last two inspection cycles (15 → 15).
All bars start at zero. Exact values and supporting details remain below.
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 0 | D |
| 2024 | 20 | 0 | F |
| 2025 | 20 | 1 | G ▲ |
| 2026 | 16 | 0 | E |
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.
How to file a complaint about care →
1 fine totaling $23,920, plus 1 Medicare payment denial period.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
| Date | Type | Amount / length |
|---|---|---|
| Jul 2, 2025 | Fine | $23,920 |
| Mar 14, 2025 | Payment Denial | 3 days from Jun 14, 2025 |
What these staffing numbers mean →
All bars start at zero. Exact values and supporting details remain below.
| Measure | This facility | Washington avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.18 | 4.24 | 3.95 | top 37% in Washington; top 33% in the U.S. |
| Registered Nurse hours | 0.98 | 0.91 | 0.69 | top 33% in Washington; top 17% in the U.S. |
| Weekend total nurse staffing | 3.82 | 3.69 | 3.50 | top 27% in Washington; top 28% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.72 | 0.67 | 0.48 | top 37% in Washington; top 15% in the U.S. |
| Total nursing staff turnover (%) | 45.1 | 45.1 | 45.8 | bottom 45% in Washington; bottom 50% in the U.S. |
| RN turnover (%) | 26.1 | 45.4 | 42.9 | top 15% in Washington; top 23% in the U.S. |
Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.88 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 5/5.
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5
Price evidence · separate from quality
No verified facility-specific private-pay price is available in our data for Washington Veteran Home-Retsil. CMS inspection and staffing records do not tell us what this home will charge you.
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Understand who pays for care · How we handle price evidence · Report an incorrect price
How to read ownership records →
Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →
Government - State
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Washington State Department of Vete | Organization | 5% or Greater Direct Ownership Interest | 100% | 03/01/2007 |
| Fang, Aaron | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/07/2024 |
| Fang, Aaron | Individual | ADP of the SNF | NOT APPLICABLE | 05/07/2024 |
| Gilbert, Solomon | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/22/2023 |
| Lysobey, Matthew | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/20/2023 |
| Lysobey, Matthew | Individual | ADP of the SNF | NOT APPLICABLE | 11/24/2025 |
| Murray, Daniel | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/16/2021 |
| Puente, David | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/01/2023 |
| Puente, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2023 |
| Westhoff, Terrance | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2020 |
All 10 owning or managing parties CMS has on file are shown — none excluded.
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Port Washington Post Acute | 2.6 mi | Bremerton, WA | ★☆☆☆☆ | 1/5 | |
| Belmont Terrace | 2.7 mi | Bremerton, WA | ★★★☆☆ | 2/5 | |
| Life Care Center of Port Orchard | 2.7 mi | Port Orchard, WA | ★★★★★ | 4/5 | |
| Avamere Rehabilitation at Ridgemont | 2.8 mi | Port Orchard, WA | ★★★★☆ | 4/5 | |
| Bremerton Trails Post Acute | 2.8 mi | Bremerton, WA | ★☆☆☆☆ | 1/5 | SFF |
| Bainbridge Island Health & Rehab Center | 7.2 mi | Bainbridge Island, WA | ★★★★★ | 5/5 | |
| Northwoods Lodge | 9.4 mi | Silverdale, WA | ★★★★★ | 4/5 | |
| Avamere Rehabilitation at Park West | 10.7 mi | Seattle, WA | ★★☆☆☆ | 2/5 | |
| Providence Mount St Vincent | 10.8 mi | Seattle, WA | ★★★☆☆ | 2/5 | |
| Avamere Rehabilitation of Burien | 12.8 mi | Burien, WA | ★★☆☆☆ | 2/5 | |
| Heron's Key | 12.9 mi | Gig Harbor, WA | ★★★★★ | 5/5 | |
| Martha and Mary Health Service | 13.3 mi | Poulsbo, WA | ★★★★☆ | 3/5 |
Facility data as of CMS processing date 2026-08-01. CCN 505517.
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