23 health deficiencies
Top issue: Resident Rights (7 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Vancouver, WA
3-star overall rating with 3-star inspections with 22 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2811 Ne 139th Street, Vancouver, WA
(360) 574-5247
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hill Valley Healthcare
Operator or chain grouping
Approved since
2011-10-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.53
Registered nurse staffing
LPN hours / resident day
1.11
Licensed practical nurse staffing
Aide hours / resident day
2.25
Nurse aide staffing
Weekend hours
3.48
Weekend nurse staffing
RN turnover
63%
Annual RN turnover
Total nurse turnover
67%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.2% |
96.0%
3.8 pts worse
|
93.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.0% |
93.8%
9.8 pts worse
|
95.5%
11.5 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.1% |
2.6%
3.5 pts worse
|
3.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 4.5% |
16.3%
11.8 pts better
|
11.4%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 8.5% |
5.8%
2.7 pts worse
|
5.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.7% |
12.1%
3.4 pts better
|
19.6%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 15.5% |
15.9%
0.4 pts better
|
16.7%
1.2 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 | 13.8% |
20.0%
6.2 pts better
|
16.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.1% |
15.8%
1.7 pts better
|
14.9%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.2%
0.2 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.0% |
23.5%
2.5 pts better
|
19.8%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
4.7%
0.3 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.8% |
87.7%
1.9 pts worse
|
81.7%
4.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.6% |
13.2%
6.4 pts worse
|
12.0%
7.6 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.4%
0.6 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.4% |
82.0%
17.6 pts worse
|
79.7%
15.3 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.1% |
19.9%
7.2 pts worse
|
23.9%
3.2 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Resident Rights (7 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
28 fire-safety deficiencies
Top issue: Emergency Preparedness (23 deficiencies)
Fire safety
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-02-08
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2026-02-08
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 2026-02-08
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2026-02-08
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2026-02-08
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-11-20
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-11-20
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-11-20
Fire Safety
Meet other general requirements.
Corrected 2024-11-20
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-20
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-20
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-20
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-20
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-20
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-02-09
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-01-09
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-01-09
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-02-09
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-01-09
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-01-09
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-01-09
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-01-09
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-01-09
Fire Safety
Develop a communication plan.
Corrected 2024-02-09
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-02-09
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-02-09
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-02-09
Fire Safety
Establish methods for sharing information.
Corrected 2024-01-09
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-02-09
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-02-09
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-01-09
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-01-09
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-02-09
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-02-09
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-01-09
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-01-09
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-02-09
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-01-09
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-09
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-01-09
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-09
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-01-09
Inspection history
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 2026-02-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-02-20
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-02-20
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2026-02-20
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2026-02-20
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 2026-02-20
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-02-20
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-02-20
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-02-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-02-20
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-02-20
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-20
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-02-20
Health
Post nurse staffing information every day.
Corrected 2026-02-20
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-20
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2026-01-23
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-23
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-23
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-12
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-09-26
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-09-26
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-26
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-26
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-12-02
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-02
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-12-02
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-12-02
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-02
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-02
Health
Report COVID19 data to residents and families.
Corrected 2024-12-02
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-25
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-25
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-30
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-03
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 2024-01-11
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-01-11
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 2024-01-11
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-01-11
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 2024-01-11
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-11
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-11
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-11
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-11
Health
Post nurse staffing information every day.
Corrected 2024-01-11
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-18
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-22
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-19
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
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