Cycle 1
Health 2025-01-27 · Fire 2025-01-27
8 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Vancouver, WA
The Oaks At Timberline
5-star overall rating with 5-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
400 East 33rd Street, Vancouver, WA
(360) 696-2561
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1970-11-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 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
0.41
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.21
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.37
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.99
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.25
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
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,631
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.16
Composite VBP score used to determine payment impact.
Payment multiplier
1.0101
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.90
Baseline 22.23% · Performance 18.38% · Measure score 6.90 · Achievement 6.59 · Improvement 6.90
Healthcare-associated infections
7.27
Baseline 6.61% · Performance 5.66% · Measure score 7.27 · Achievement 7.27 · Improvement 5.39
Total nurse turnover
4.67
Baseline 57.89% · Performance 44.59% · Measure score 4.67 · Achievement 4.67 · Improvement 3.52
Adjusted total nurse staffing
3.22
Baseline 4.17 hours · Performance 3.99 hours · Measure score 3.22 · Achievement 3.22 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.41% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 9.76% · Lower 95% interval 7.89% |
| Discharge to community | 62.6% |
50.57%
12 pts better
|
Better than the National Rate · Eligible stays 117 · Observed rate 59.83% · Lower 95% interval 54.66% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 75.28% |
95.27%
20 pts worse
|
Numerator 67 · Denominator 89 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 89 |
| Discharge self-care score | 53.03% |
53.69%
0.7 pts worse
|
Numerator 35 · Denominator 66 |
| Discharge mobility score | 62.12% |
50.94%
11.2 pts better
|
Numerator 41 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 4.49% |
2.29%
2.2 pts worse
|
Numerator 4 · Denominator 89 · Adjusted rate 5.05% |
| Healthcare-associated infections requiring hospitalization | 5.66% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 1.49% · Lower 95% interval 3.17% |
| Staff COVID-19 vaccination coverage | 21.93% |
8.2%
13.7 pts better
|
Numerator 25 · Denominator 114 |
| Staff flu vaccination coverage | 44.78% |
42%
2.8 pts better
|
Numerator 60 · Denominator 134 |
| Discharge function score | 54.55% |
56.45%
1.9 pts worse
|
Numerator 36 · Denominator 66 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.49% |
96.28%
0.2 pts better
|
Numerator 55 · Denominator 57 |
| Resident COVID-19 vaccinations up to date | 35.29% |
25.2%
10.1 pts better
|
Numerator 18 · Denominator 51 |
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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.5% |
93.8%
6.3 pts worse
|
95.5%
8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 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 who have depressive symptoms | 18.1% |
16.3%
1.8 pts worse
|
11.4%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 22.9% · Q3 20.0% · Q4 17.6% · 4Q avg 18.1% |
| Percentage of long-stay residents who lose too much weight | 0.5% |
5.8%
5.3 pts better
|
5.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.7% |
12.1%
1.4 pts better
|
19.6%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 14.0% · Q3 10.2% · Q4 7.8% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.6% |
15.9%
7.3 pts better
|
16.7%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 9.1% · Q3 7.7% · Q4 9.3% · 4Q avg 8.6% · 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 | 10.8% |
20.0%
9.2 pts better
|
16.3%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.7% |
15.8%
5.1 pts better
|
14.9%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 8.3% · Q3 13.0% · Q4 12.5% · 4Q avg 10.7% · Used in QM five-star |
| 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 · 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 a urinary tract infection | 1.0% |
1.7%
0.7 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.7% |
23.5%
0.2 pts worse
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 22.2% · Q3 21.4% · Q4 25.3% · 4Q avg 23.7% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.7%
4.7 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
87.7%
8.9 pts better
|
81.7%
14.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 97.1% · Q3 97.7% · Q4 96.9% · 4Q avg 96.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
13.2%
2.9 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 15.4% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.4%
1.1 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.1% |
82.0%
6.1 pts better
|
79.7%
8.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.3% |
19.9%
2.6 pts better
|
23.9%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 14.1% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-07 · Fire 2024-02-07
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-03-27 · Fire 2023-03-27
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
14 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-27
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-20
F · Potential for more than minimal harm
2025-01-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-27
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-27
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-02-28
F · Potential for more than minimal harm
2024-02-07
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-03-29
F · Potential for more than minimal harm
2024-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-29
F · Potential for more than minimal harm
2024-02-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-29
F · Potential for more than minimal harm
2023-03-27
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-03-27
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-03-27
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-03-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-03-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-03-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-03-27
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 2023-04-12
F · Potential for more than minimal harm
2023-03-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-03-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-12
E · Potential for more than minimal harm
2023-03-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-27
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-27
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-04-12
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-27
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 2025-03-07
D · Potential for more than minimal harm
2025-01-27
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 2025-03-07
D · Potential for more than minimal harm
2025-01-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-27
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-27
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-27
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 2025-03-07
D · Potential for more than minimal harm
2025-01-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-07
D · Potential for more than minimal harm
2024-08-12
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 2024-08-30
E · Potential for more than minimal harm
2024-02-07
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 2024-03-04
D · Potential for more than minimal harm
2024-02-07
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 2024-03-04
F · Potential for more than minimal harm
2023-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-03-27
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 2023-04-26
D · Potential for more than minimal harm
2023-03-27
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 2023-04-26
D · Potential for more than minimal harm
2023-03-27
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 2023-04-26
D · Potential for more than minimal harm
2023-03-27
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 2023-04-26
D · Potential for more than minimal harm
2023-03-27
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 2023-04-26
D · Potential for more than minimal harm
2023-03-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-27
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-27
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 2023-04-26
C · Minimal harm
2023-03-27
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-04-26
Penalties and ownership
What sits behind the stars
Ownership
Pennant Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Fitch, Craig
Corporate Officer · Individual
Hoopes, Tyler
Corporate Director · Individual
Jenkins, Tracy
Corporate Officer · Individual
Newberry, Collin
Contracted Managing Employee · Individual
Newberry, Collin
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Bridge Crest Post Acute
Vancouver, WA
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
#2
Vancouver Specialty And Rehab Care
Vancouver, WA
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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