Cycle 1
Health 2025-07-02 · Fire 2025-07-02
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Bellingham, WA
Mt Baker Care Center
5-star overall rating with 5-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2905 Connelly Avenue, Bellingham, WA
(360) 734-4181
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
55
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Regency Pacific Management
Operator or chain grouping
Approved since
1991-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
27 facilities
Chain averages 4 overall / 3 health / 4 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
1.23
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
3.24
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
5.30
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
2.06
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
4.57
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.97
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.06
CMS adjusted RN staffing hours
Adjusted total hours
4.53
CMS adjusted total nurse staffing hours
Case-mix index
1.60
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
571
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
67.31
Composite VBP score used to determine payment impact.
Payment multiplier
1.0209
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.95
Baseline 14.67% · Performance 18.21% · Measure score 6.95 · Achievement 6.95 · Improvement 0
Healthcare-associated infections
9.37
Baseline 4.62% · Performance 5.04% · Measure score 9.37 · Achievement 9.37 · Improvement 0
Total nurse turnover
6.05
Baseline 45.56% · Performance 38.96% · Measure score 6.05 · Achievement 6.05 · Improvement 2.69
Adjusted total nurse staffing
4.56
Baseline 4.66 hours · Performance 4.38 hours · Measure score 4.56 · Achievement 4.56 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.03% |
10.72%
2.7 pts better
|
No Different than the National Rate · Eligible stays 258 · Observed rate 4.26% · Lower 95% interval 6.38% |
| Discharge to community | 58.52% |
50.57%
8 pts better
|
Better than the National Rate · Eligible stays 255 · Observed rate 57.65% · Lower 95% interval 52.38% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.33% |
95.27%
0.1 pts better
|
Numerator 143 · Denominator 150 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 150 |
| Discharge self-care score | 58.02% |
53.69%
4.3 pts better
|
Numerator 76 · Denominator 131 |
| Discharge mobility score | 64.89% |
50.94%
14 pts better
|
Numerator 85 · Denominator 131 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 150 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.04% |
7.12%
2.1 pts better
|
No Different than the National Rate · Eligible stays 150 · Observed rate 1.33% · Lower 95% interval 2.83% |
| Staff COVID-19 vaccination coverage | 0.7% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 143 |
| Staff flu vaccination coverage | 23.78% |
42%
18.2 pts worse
|
Numerator 34 · Denominator 143 |
| Discharge function score | 52.67% |
56.45%
3.8 pts worse
|
Numerator 69 · Denominator 131 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 103 · Denominator 103 |
| Resident COVID-19 vaccinations up to date | 40.51% |
25.2%
15.3 pts better
|
Numerator 32 · Denominator 79 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.4
0.6 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.5
0.8 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
96.0%
0.2 pts better
|
93.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 94.9% · Q3 94.7% · Q4 100.0% · 4Q avg 96.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
93.8%
3.8 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 11.5% |
2.6%
8.9 pts worse
|
3.3%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 12.8% · Q3 10.5% · Q4 10.5% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 50.3% |
16.3%
34 pts worse
|
11.4%
38.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 61.5% · Q2 50.0% · Q3 48.6% · Q4 40.5% · 4Q avg 50.3% |
| Percentage of long-stay residents who lose too much weight | 0.8% |
5.8%
5 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.1% |
12.1%
4 pts better
|
19.6%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 8.6% · Q3 6.2% · Q4 9.7% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.8% |
15.9%
9.9 pts worse
|
16.7%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 25.0% · Q3 29.6% · Q4 22.6% · 4Q avg 25.8% · 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 | 30.6% |
20.0%
10.6 pts worse
|
16.3%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.6% · 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 41.7% · Q2 25.0% · Q3 13.3% · Q4 13.8% · 4Q avg 24.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.2%
0.6 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.7%
0.4 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 2.6% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.8% |
23.5%
4.3 pts worse
|
19.8%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 20.5% · Q3 35.8% · Q4 26.8% · 4Q avg 27.8% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
4.7%
3.6 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.4% · Q3 1.5% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
87.7%
11 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 99.2% · Q3 99.2% · Q4 100.0% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.4% |
13.2%
6.8 pts better
|
12.0%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.4% · Observed 6.2% · Expected 10.7% · 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 2.4% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.9% |
82.0%
14.9 pts better
|
79.7%
17.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.4% |
19.9%
0.5 pts better
|
23.9%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 17.1% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-12 · Fire 2024-04-12
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-01-07 · Fire 2023-01-07
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-31
F · Potential for more than minimal harm
2025-07-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-07-31
F · Potential for more than minimal harm
2024-04-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-08
F · Potential for more than minimal harm
2024-04-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-08
E · Potential for more than minimal harm
2024-04-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-08
E · Potential for more than minimal harm
2024-04-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-04-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-04-12
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-05-08
F · Potential for more than minimal harm
2023-01-07
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-02-01
F · Potential for more than minimal harm
2023-01-07
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-02-01
F · Potential for more than minimal harm
2023-01-07
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-02-01
F · Potential for more than minimal harm
2023-01-07
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-02-01
F · Potential for more than minimal harm
2023-01-07
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-02-01
F · Potential for more than minimal harm
2023-01-07
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-02-01
F · Potential for more than minimal harm
2023-01-07
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-02-03
F · Potential for more than minimal harm
2023-01-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-03
F · Potential for more than minimal harm
2023-01-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-03
F · Potential for more than minimal harm
2023-01-07
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-02-03
E · Potential for more than minimal harm
2023-01-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-03
D · Potential for more than minimal harm
2023-01-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-02-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-20
D · Potential for more than minimal harm
2025-07-02
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 2025-07-31
D · Potential for more than minimal harm
2025-07-02
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 2025-07-31
D · Potential for more than minimal harm
2025-07-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-31
E · Potential for more than minimal harm
2024-04-12
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 2024-05-10
D · Potential for more than minimal harm
2024-04-12
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-12
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 2024-05-10
D · Potential for more than minimal harm
2024-04-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-12
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-03-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-07
F · Potential for more than minimal harm
2023-01-07
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-02-15
F · Potential for more than minimal harm
2023-01-07
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 2023-02-15
D · Potential for more than minimal harm
2023-01-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-15
D · Potential for more than minimal harm
2023-01-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-02-15
D · Potential for more than minimal harm
2023-01-07
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-02-15
Penalties and ownership
What sits behind the stars
Ownership
Clay, James
5% Or Greater Direct Ownership Interest · Individual
Clay Management Group LLC
Operational/Managerial Control · Organization
Clay, James
Corporate Director · Individual
Reis-Elbara, Catherine
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Highland Health And Rehabilitation Of Cascadia
Bellingham, WA
4-star overall rating with 4-star inspections with $53,339 in total fines with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Shuksan Rehabilitation And Health Care
Bellingham, WA
1-star overall rating with 1-star inspections with $73,622 in total fines with 24 recent health deficiencies with 28 fire-safety deficiencies in the latest cycle
#3
Avalon Healthcare Bellingham
Bellingham, WA
4-star overall rating with 3-star inspections with $106,024 in total fines with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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