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
Chain footprint
40 facilities
Chain averages 2 overall / 2 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
RN hours / resident day
0.53
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.11
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.25
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.89
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.48
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
4.08
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
3,926
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9950
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.32
Baseline 17.88% · Performance 19.43% · Measure score 4.32 · Achievement 4.32 · Improvement 0
Healthcare-associated infections
10
Baseline 5.48% · Performance 4.49% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
0
Baseline 47.73% · Performance 69.49% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.52
Baseline 3.89 hours · Performance 3.79 hours · Measure score 2.52 · Achievement 2.52 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.59% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 346 · Observed rate 9.54% · Lower 95% interval 8.18% |
| Discharge to community | 68.99% |
50.57%
18.4 pts better
|
Better than the National Rate · Eligible stays 372 · Observed rate 65.32% · Lower 95% interval 65.06% |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.87% |
95.27%
0.6 pts better
|
Numerator 232 · Denominator 242 |
| Falls with major injury | 0.41% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 242 |
| Discharge self-care score | 41.18% |
53.69%
12.5 pts worse
|
Numerator 70 · Denominator 170 |
| Discharge mobility score | 41.76% |
50.94%
9.2 pts worse
|
Numerator 71 · Denominator 170 |
| Pressure ulcers or injuries, new or worsened | 0.41% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 242 · Adjusted rate 0.6% |
| Healthcare-associated infections requiring hospitalization | 4.49% |
7.12%
2.6 pts better
|
No Different than the National Rate · Eligible stays 208 · Observed rate 1.44% · Lower 95% interval 2.76% |
| Staff COVID-19 vaccination coverage | 11.35% |
8.2%
3.2 pts better
|
Numerator 16 · Denominator 141 |
| Staff flu vaccination coverage | 9.78% |
42%
32.2 pts worse
|
Numerator 22 · Denominator 225 |
| Discharge function score | 48.24% |
56.45%
8.2 pts worse
|
Numerator 82 · Denominator 170 |
| Transfer of health information to provider | 95% |
95.95%
1 pts worse
|
Numerator 57 · Denominator 60 |
| Transfer of health information to patient | 89.82% |
96.28%
6.5 pts worse
|
Numerator 150 · Denominator 167 |
| Resident COVID-19 vaccinations up to date | 12.31% |
25.2%
12.9 pts worse
|
Numerator 16 · Denominator 130 |
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 · Q1 92.5% · Q2 93.3% · Q3 88.4% · Q4 94.1% · 4Q avg 92.2% |
| 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 · 4Q avg 84.0% |
| 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 · Q1 10.0% · Q2 8.9% · Q3 4.7% · Q4 2.0% · 4Q avg 6.1% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 7.5% · Q3 5.6% · Q4 4.3% · 4Q avg 4.5% |
| 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 · Q1 5.3% · Q2 12.2% · Q3 10.0% · Q4 6.5% · 4Q avg 8.5% |
| 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 · Q1 13.2% · Q2 11.6% · Q3 4.8% · Q4 6.1% · 4Q avg 8.7% |
| 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 · Q1 9.4% · Q2 13.8% · Q3 19.4% · Q4 17.8% · 4Q avg 15.5% · 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 | 13.8% |
20.0%
6.2 pts better
|
16.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.8% · Used in QM five-star |
| 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 · Q1 2.6% · Q2 28.6% · Q3 7.3% · Q4 16.3% · 4Q avg 14.1% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 4.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 24.8% · Q2 32.1% · Q3 9.9% · Q4 17.7% · 4Q avg 21.0% |
| 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 · Q1 6.9% · Q2 4.6% · Q3 5.0% · Q4 3.9% · 4Q avg 5.0% · Used in QM five-star |
| 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 · Q1 85.3% · Q2 85.0% · Q3 85.0% · Q4 87.7% · 4Q avg 85.8% |
| 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 · Adjusted 19.6% · Observed 18.5% · Expected 10.5% · Used in QM five-star |
| 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 · Q1 0.8% · Q2 0.8% · Q3 1.3% · Q4 0.5% · 4Q avg 0.8% · Used in QM five-star |
| 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 · 4Q avg 64.4% |
| 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 · Adjusted 27.1% · Observed 22.5% · Expected 19.8% · Used in QM five-star |
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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