Cycle 1
Health 2025-12-12 · Fire 2025-12-12
22 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Vancouver, WA
Bridge Crest Post Acute
2-star overall rating with 2-star inspections with $197,832 in total fines with 22 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
5220 Northeast Hazel Dell Avenue, Vancouver, WA
(360) 693-1474
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
89
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1989-06-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.69
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.06
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.79
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
4.72
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,659
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.94
Composite VBP score used to determine payment impact.
Payment multiplier
1.0099
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.37
Baseline 20.83% · Performance 18.02% · Measure score 7.37 · Achievement 7.37 · Improvement 6.90
Healthcare-associated infections
7.1
Baseline 6.19% · Performance 5.71% · Measure score 7.1 · Achievement 7.1 · Improvement 3.48
Total nurse turnover
0
Baseline 50.00% · Performance 64.49% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
7.51
Baseline 4.55 hours · Performance 5.21 hours · Measure score 7.51 · Achievement 7.51 · Improvement 4.90
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.26% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 10.53% · Lower 95% interval 7.63% |
| Discharge to community | 66.26% |
50.57%
15.7 pts better
|
Better than the National Rate · Eligible stays 140 · Observed rate 57.14% · Lower 95% interval 56.53% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 84 · Denominator 84 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 84 |
| Discharge self-care score | 29.31% |
53.69%
24.4 pts worse
|
Numerator 17 · Denominator 58 |
| Discharge mobility score | 31.03% |
50.94%
19.9 pts worse
|
Numerator 18 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 3 · Denominator 84 · Adjusted rate 3.23% |
| Healthcare-associated infections requiring hospitalization | 5.71% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 2.7% · Lower 95% interval 3.45% |
| Staff COVID-19 vaccination coverage | 5.32% |
8.2%
2.9 pts worse
|
Numerator 5 · Denominator 94 |
| Staff flu vaccination coverage | 30.19% |
42%
11.8 pts worse
|
Numerator 32 · Denominator 106 |
| Discharge function score | 41.38% |
56.45%
15.1 pts worse
|
Numerator 24 · Denominator 58 |
| Transfer of health information to provider | 96.15% |
95.95%
0.2 pts better
|
Numerator 25 · Denominator 26 |
| Transfer of health information to patient | 97.56% |
96.28%
1.3 pts better
|
Numerator 40 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 23.81% |
25.2%
1.4 pts worse
|
Numerator 10 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.3% |
96.0%
1.7 pts worse
|
93.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.5% · Q2 96.0% · Q3 94.3% · Q4 94.0% · 4Q avg 94.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.2% |
93.8%
0.6 pts worse
|
95.5%
2.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
2.6%
2.6 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 6.0% · Q3 5.7% · Q4 2.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.2% |
16.3%
6.1 pts better
|
11.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 7.3% · Q3 7.0% · Q4 13.3% · 4Q avg 10.2% |
| Percentage of long-stay residents who lose too much weight | 9.1% |
5.8%
3.3 pts worse
|
5.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 12.5% · Q3 7.5% · Q4 2.0% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.6% |
12.1%
3.5 pts better
|
19.6%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 10.4% · Q3 9.4% · Q4 6.1% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.7% |
15.9%
0.8 pts worse
|
16.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 16.0% · Q3 18.5% · Q4 23.3% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 36.1% |
20.0%
16.1 pts worse
|
16.3%
19.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.4% |
15.8%
8.6 pts worse
|
14.9%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 22.2% · Q3 28.0% · Q4 26.7% · 4Q avg 24.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.9% |
1.2%
1.7 pts worse
|
1.0%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.8% · Q3 3.0% · Q4 3.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.7%
0.4 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 1.9% · Q4 4.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.9% |
23.5%
6.6 pts better
|
19.8%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 19.0% · Q3 21.0% · Q4 4.2% · 4Q avg 16.9% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
4.7%
1.7 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 5.0% · Q3 9.1% · Q4 4.0% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.1% |
87.7%
23.6 pts worse
|
81.7%
17.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 67.9% · Q2 65.7% · Q3 68.6% · Q4 54.4% · 4Q avg 64.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.7% |
13.2%
11.5 pts worse
|
12.0%
12.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 24.6% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.4%
0.3 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 2.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.4% |
82.0%
18.6 pts worse
|
79.7%
16.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
19.9%
3.5 pts worse
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 23.0% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-11 · Fire 2024-10-11
20 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
22 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Cycle 3
Health 2023-11-14 · Fire 2023-11-14
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-12
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2026-01-16
F · Potential for more than minimal harm
2025-12-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2026-01-16
F · Potential for more than minimal harm
2025-12-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-16
F · Potential for more than minimal harm
2025-12-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-16
F · Potential for more than minimal harm
2025-12-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-16
F · Potential for more than minimal harm
2025-12-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-16
F · Potential for more than minimal harm
2025-12-12
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-12-12
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-12-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-12-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-01-16
F · Potential for more than minimal harm
2024-10-11
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-10-28
F · Potential for more than minimal harm
2024-10-11
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-10-28
F · Potential for more than minimal harm
2024-10-11
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-10-28
F · Potential for more than minimal harm
2024-10-11
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-10-28
F · Potential for more than minimal harm
2024-10-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-11-13
F · Potential for more than minimal harm
2024-10-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-10-28
F · Potential for more than minimal harm
2024-10-11
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-11-14
F · Potential for more than minimal harm
2024-10-11
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-10-16
F · Potential for more than minimal harm
2024-10-11
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-11-14
F · Potential for more than minimal harm
2024-10-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-14
F · Potential for more than minimal harm
2024-10-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-14
F · Potential for more than minimal harm
2024-10-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-10-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-14
F · Potential for more than minimal harm
2024-10-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-14
F · Potential for more than minimal harm
2024-10-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-14
F · Potential for more than minimal harm
2024-10-11
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-11-14
F · Potential for more than minimal harm
2024-10-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-14
F · Potential for more than minimal harm
2024-10-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-14
F · Potential for more than minimal harm
2024-10-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-14
F · Potential for more than minimal harm
2024-10-11
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-11-14
E · Potential for more than minimal harm
2024-10-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-14
J · Immediate jeopardy
2023-11-14
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2023-11-08
F · Potential for more than minimal harm
2023-11-14
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-11-20
F · Potential for more than minimal harm
2023-11-14
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-11-20
F · Potential for more than minimal harm
2023-11-14
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-11-20
F · Potential for more than minimal harm
2023-11-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-20
F · Potential for more than minimal harm
2023-11-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-11-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-11-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-11-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-10
E · Potential for more than minimal harm
2025-12-12
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2026-01-10
E · Potential for more than minimal harm
2025-12-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-12-12
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-12-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-12-12
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-12-12
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-12-12
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-12-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-12-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-12-12
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-12-12
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-12-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-12-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-12-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2026-01-10
G · Actual harm
2025-10-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-28
D · Potential for more than minimal harm
2025-09-04
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-09-04
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-25
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-04
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-08-29
G · Actual harm
2025-04-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-27
G · Actual harm
2025-03-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-12
G · Actual harm
2025-02-27
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-03-22
F · Potential for more than minimal harm
2024-10-11
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-11-14
E · Potential for more than minimal harm
2024-10-11
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-11
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-11
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-11
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-11
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-11
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-11
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-11
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-11
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-11
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-11
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-03-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-17
J · Immediate jeopardy
2023-11-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-12
J · Immediate jeopardy
2023-11-14
F906 · Environmental Deficiencies
Health
Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers.
Corrected 2023-12-12
G · Actual harm
2023-11-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-12
E · Potential for more than minimal harm
2023-11-14
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-12-12
E · Potential for more than minimal harm
2023-11-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-12
E · Potential for more than minimal harm
2023-11-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-14
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-12-12
G · Actual harm
2023-10-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-22
D · Potential for more than minimal harm
2023-04-14
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-05-03
Penalties and ownership
What sits behind the stars
$107,738
2025-04-24
Fine
Fine · fine $107,738
Fine
$54,649
2025-02-27
Fine
Fine · fine $54,649
Fine
$28,002
2023-11-14
Fine
Fine · fine $28,002
Fine
$7,443
2023-10-02
Fine
Fine · fine $7,443
Fine
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Operational/Managerial Control · Individual
Apt, Frederick
Corporate Officer · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Murray, Jason
Corporate Director · Individual
Olmstead, Stacey
Operational/Managerial Control · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
General Partnership Interest · Organization
Truist Bank
5% Or Greater Security Interest · Organization
Van Auken, Matthew
Operational/Managerial Control · Individual
Warren, Christopher
Operational/Managerial Control · Individual
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5-star overall rating with 5-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
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4-star overall rating with 4-star inspections with $58,607 in total fines with 11 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Hudson Bay Health And Rehabilitation
Vancouver, WA
5-star overall rating with 4-star inspections with $65,861 in total fines with 5 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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