Cycle 1
Health 2025-04-24 · Fire 2025-04-24
5 health deficiencies
Top issue: Environmental (1 deficiency)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Vancouver, WA
Hudson Bay Health And Rehabilitation
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
8507 Northeast 8th Way, Vancouver, WA
(360) 254-5335
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
92
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cascadia Healthcare
Operator or chain grouping
Approved since
1981-10-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.01
Registered nurse staffing
LPN hours / resident day
0.70
Licensed practical nurse staffing
Aide hours / resident day
2.20
Nurse aide staffing
Weekend hours
3.38
Weekend nurse staffing
RN turnover
61%
Annual RN turnover
Total nurse turnover
67%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.0%
4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.3% |
93.8%
2.5 pts better
|
95.5%
0.8 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
2.6%
0.4 pts worse
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 7.2% |
16.3%
9.1 pts better
|
11.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.8%
1.1 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.4% |
12.1%
1.7 pts better
|
19.6%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 15.1% |
15.9%
0.8 pts better
|
16.7%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.5% |
20.0%
6.5 pts worse
|
16.3%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.2% |
15.8%
5.6 pts better
|
14.9%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.2%
1.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 4.1% |
1.7%
2.4 pts worse
|
1.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.9% |
23.5%
4.6 pts better
|
19.8%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
4.7%
1.7 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
87.7%
4 pts better
|
81.7%
10 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.4% |
13.2%
0.8 pts better
|
12.0%
0.4 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.4%
0.1 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.0% |
82.0%
6 pts better
|
79.7%
8.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.5% |
19.9%
6.4 pts better
|
23.9%
10.4 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-07 · Fire 2024-06-07
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Cycle 3
Health 2023-05-08 · Fire 2023-05-08
14 health deficiencies
Top issue: Resident Rights (6 deficiencies)
20 fire-safety deficiencies
Top issue: Emergency Preparedness (9 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-24
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-05-21
F · Potential for more than minimal harm
2025-04-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-21
F · Potential for more than minimal harm
2025-04-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-21
F · Potential for more than minimal harm
2025-04-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-29
F · Potential for more than minimal harm
2025-04-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-21
F · Potential for more than minimal harm
2025-04-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-21
F · Potential for more than minimal harm
2025-04-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-29
F · Potential for more than minimal harm
2025-04-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-21
F · Potential for more than minimal harm
2025-04-24
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-05-21
F · Potential for more than minimal harm
2025-04-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-24
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 2025-05-21
D · Potential for more than minimal harm
2025-04-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-21
F · Potential for more than minimal harm
2024-06-07
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-06-07
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-06-07
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-06-07
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-06-07
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-06-07
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-06-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-06-07
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-06-07
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-06-07
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 2024-07-09
F · Potential for more than minimal harm
2024-06-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-06-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-09
L · Immediate jeopardy
2023-05-08
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-06-05
L · Immediate jeopardy
2023-05-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-05-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-24
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 2025-05-23
D · Potential for more than minimal harm
2025-04-24
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-24
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 2025-05-23
D · Potential for more than minimal harm
2025-04-24
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 2025-05-23
D · Potential for more than minimal harm
2024-09-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-06-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-07
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 2024-06-28
D · Potential for more than minimal harm
2024-06-07
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-07
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-06-28
E · Potential for more than minimal harm
2023-09-22
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 2023-10-20
K · Immediate jeopardy
2023-05-08
F906 · Environmental Deficiencies
Health
Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
F843 · Administration Deficiencies
Health
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-05-08
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2023-06-05
E · Potential for more than minimal harm
2023-05-08
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 2023-06-05
E · Potential for more than minimal harm
2023-05-08
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 2023-06-05
E · Potential for more than minimal harm
2023-05-08
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-05-08
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 2023-06-05
D · Potential for more than minimal harm
2023-05-08
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 2023-06-05
D · Potential for more than minimal harm
2023-05-08
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 2023-06-05
Penalties and ownership
What sits behind the stars
$65,861
2023-05-08
Fine
Fine · fine $65,861
Fine
Ownership
Cascadia Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Cascadia Services LLC
Operational/Managerial Control · Organization
Dinh, Dieu
Operational/Managerial Control · Individual
Hammond, Owen
Operational/Managerial Control · Individual
Laforte, Stephen
Operational/Managerial Control · Individual
Nelson, Timothy
Operational/Managerial Control · Individual
Riley, Craig
Operational/Managerial Control · Individual
Timberline Ohi Tenant LLC
5% Or Greater Security Interest · Organization
White Oak Healthcare Finance LLC
5% Or Greater Security Interest · Organization
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