Peacehealth St Joseph Medical Center
An acute care hospital in Bellingham, Washington 98225
2901 Squalicum Parkway, Bellingham, Washington 98225. (360) 734-5400.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 4of 5 CMS’s overall rating
- 3of 5 patient survey rating
- 3 deficiencies cited in the last three years (needs attention)
- 253 beds
Each figure’s source sits beside it, in its section below.
What these words mean4
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
- Condition-level deficiency
- For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual.
What did inspectors find?
The last inspection on record was on Aug 20, 2024: a complaint inspection.
3 deficiencies cited in the last three years, 1 of them at condition level, the most serious.
1 deficiency at condition level, the more serious of CMS’s two levels
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
3 deficiencies in 1 month of the last 36. Last cited Apr 2024. Most serious: Condition-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Apr 24, 2024: complaint inspection3 deficiencies
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Nursing Services
The inspectors’ words, 191 words
“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 45663 . Based on observation, interview, and document review, the hospital failed to ensure the Hospital operated under one unified nursing service under the direction of one Registered Nurse who was responsible for the quality of care provided to hospital patients by hospital and non-hospital nursing staff. Failure to ensure that Nursing Services are provided under the direction of one hospital-wide nursing service under the direction of one Registered Nurse accountable for the quality of nursing care provided to its patient’s places patients at risk for inconsistent or inadequate care, adverse outcomes, and death. Findings included: 1. The hospital failed to ensure that PeaceHealth St Joseph Medical Center operated with one hospital-wide Nursing Service, and failed to ensure that a single nursing service was under the direction of one Registered Nurse (RN) responsible for the operation of the services and the quality of the patient care provided by nursing services. Cross Reference: A0386 .”
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Chief Executive Officer
The inspectors’ words, 239 words
“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 45663 . Based on interview and document review, the Governing Body failed to ensure that the appointed Chief Executive Officer (CEO) was responsible for managing the entire hospital to include offsite clinics under the hospital license. Failure to appoint a Chief Executive Officer to manage the entire hospital risks ineffective oversight and inadequate management of the hospital by one responsible individual. Findings included: 1. On 04/05/24 at 10:45 AM, Surveyor #5 and Surveyor #9, the Chief Operating Officer (Staff #904), Chief Nursing Officer designee (Staff #907), and Chief Executive Officer (Staff #908) reviewed an organizational chart titled, “PHMG Northwest Network,” updated on 01/15/24, which showed off site services provided by the hospital. 2. At the time of the review, Staff #908 verified that the services provided at the offsite hospital facilities to include: PeaceHealth Senior Health at Medical Office Plaza, PeaceHealth Orthopedics, Sports Medicine and Trauma Surgery, and PeaceHealth Neurology at Cascade Brain and Spine Center, report directly to the Vice President PeaceHealth Medical Group. Staff #908 stated that himself, the Vice President of Operations, and the Chief Medical Officer of the PeaceHealth Medical Group have a “collegial” relationship. Staff #908 stated that they meet regularly but there was no direct reporting relationship to the hospital Chief Executive Officer. .”
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Organization Of Nursing Services
The inspectors’ words, 764 words
“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 45663 . Based on interview and document review, the hospital failed to ensure that PeaceHealth St Joseph Medical Center hospital operated with one hospital-wide Nursing Service, and failed to ensure that a single nursing service was under the direction of one Registered Nurse (RN) responsible for the operation of the service and the quality of the patient care provided by nursing services. Failure to ensure that Nursing Services are provided under the direction of one hospital-wide nursing service under the direction of one Registered Nurse places patients at risk for suboptimal care, adverse outcomes, and death. Findings included: 1. Document review of the Chief Nursing Officer (CNO) Northwest Job Description showed that the CNO was accountable for the overall clinical outcomes, operations, nursing practice, and financial performance for the assigned areas. Document review of the hospital’s organizational chart for nursing titled, “PeaceHealth St Joseph Medical Center,” dated March 2024, showed the following: a. The Medical/Surgical units, float pool, Infusion Services, House Managers, Intensive Care Unit, Progressive Care Unit, Respiratory therapy, Care management, Behavioral Health, Childbirth Center, Pediatrics, Emergency department and Pharmacy were assigned and directly reported to the Chief Nursing Officer. b. Perioperative Services including Surgery, Same Day Surgery, Short Stay Unit, Post Anesthesia Unit, Endoscopy, Sterile Processing Department, and Imaging were assigned and reported directly to the Chief Operating Officer. c. The Wound Healing Center and Cardiovascular Center were assigned and reported directly to the Executive Director of Cardiovascular Services who reported to the Chief Operating Officer. d. The Cancer Center reported directly to the Vice President of Operations of the PeaceHealth Medical Group. e. The organizational chart showed a dotted line or matrixed reporting (reporting to more than one leader) to the Chief Nursing Officer for Perioperative Services, Nurse Manager Wound Healing Center, Nurse Manager Cardiovascular Services, and Nurse Manager Oncology Services. Document review of the Director of Perioperative Services (Staff #903) job evaluation titled, “Performance Review Period July 1, 2022-June 30, 2023,” showed that the review was completed and signed by this person’s manager identified in the document as the Chief Operating Officer (Staff #904). Investigator #9 found no evidence the CNO was responsible for the operation of the service Perioperative Services or evaluated the performance of the Perioperative Nursing Director (Staff #903) as part of his/her responsibility for a single nursing service under the direction of one Registered Nurse. Document review of the Job Description for the job title, Executive Director Cardiovascular Services, showed that an essential function of the position is supervising management, technical, nursing, and administrative staff. Document review of the Nurse Manager Wound Healing Center (Staff #905) job evaluation titled, “Performance Review Period July 1, 2022-June 30, 2023,” showed that the review was completed and signed by this person’s manager identified in the document as the Executive Director Cardiovascular Services (Staff #906). Investigator #9 found no evidence the CNO was responsible for the operation of the Wound Healing Center or evaluated the performance of the Nurse Manager (Staff #905) as part of his/her responsibility for a single nursing service under the direction of one Registered Nurse. 2. On 04/04//24 at 3:00 PM, Investigator #5 and Investigator #9 and Chief Operating Officer (Staff #904), Chief Nursing Officer designee (Staff #907), and Chief Executive Officer (Staff #908) reviewed the hospital’s organizational chart and oversight and responsibility for nursing services provided to patients at PeaceHealth St Joseph Medical Center. 3. At the time of the review, Staff #904 verified that the organizational chart showed that Perioperative Services including Surgery, Same Day Care, Short Stay Unit, Post Anesthesia Unit, Endoscopy, Cardiovascular Center, and Wound Care reported up through him. He stated that the CNO provided oversight and direction of staffing and other nursing practices although the staff directly reported to them. Staff #904 verified that they had completed the evaluation of the Director of Nursing for Perioperative Services and the Executive Director of Cardiovascular Services. 4. At the time of the review, Staff #906 verified that they had completed the evaluation of the Nurse Manager of the Wound Healing Center and there was no input from the CNO into that evaluation. .”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Aug 20, 2024 | Complaint inspection | No deficiencies cited |
| Apr 24, 2024 | Complaint inspection | 3 deficiencies cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 4 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 1 better and 0 worse of 8; safety of care, 2 better and 0 worse of 7; readmission, 2 better and 0 worse of 11.
- Patients rate it 3 of 5 in CMS’s patient survey (436 surveys completed, Oct 1, 2024 to Sep 30, 2025): 61% rated it 9 or 10 out of 10, and 65% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), no different than national benchmark; catheter urinary tract infections (CAUTI), better than the national benchmark; surgical site infections after colon surgery, no different than national benchmark; MRSA bloodstream infections, better than the national benchmark; C. diff infections, better than the national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 12.4%, heart failure 11.1%, pneumonia 11.9%, COPD 10.8%, stroke 9.6%, heart bypass surgery 2.6%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 15.1%, heart failure 21.9%, pneumonia 16.2%, COPD 20.1%, heart bypass surgery 11.5%, hip or knee replacement 4.6%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 210 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 3% left before being seen.
- 58% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 0.96 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 4 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 3 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jul 1, 1966.
- Ownership: voluntary non-profit - other.
- It is accredited by DNV, whose surveys stand in for the state’s routine inspections.
- Cited at For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. in the last three years: it didn’t meet a whole condition of Medicare’s rules for hospitals.
- It has an inpatient rehabilitation unit of 14 beds, which CMS lists apart as a rehabilitation facility.
- Voluntary non-profit - Other.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 3 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 3 of 5.
- 89% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Peacehealth owns 100% directly since Nov 21, 2007.
- Peacehealth runs it.
- 20 owners or officers are people: Kevin G Murphy (corporate director, 0%); Charlotte Virgia Davenport (corporate director, 0%); Ione S Adams (corporate director, 0%); Leonard W Kearney (corporate director, 0%); Thomas Karnes (corporate officer, 0%); Lorraine Arvin (corporate director, 0%); Danny W Hollingshead (corporate director, 0%); Richard Harry Wollenberg (corporate director, 0%); Timothy Ackman (corporate director, 0%); Carolyn Aaron (corporate director, 0%); Arthur Craig Springer II (corporate officer, 0%); Linda Lea Jackson (corporate director, 0%); Linda Lea Jackson (managing employee (on the payroll), 0%); Richard E Magnuson (corporate officer, 0%); Mary Mcwilliams (corporate director, 0%); Kathleen Lee Pruitt (corporate director, 0%); Sheila Lemieux (corporate director, 0%); Sarah Marie Ness (corporate officer, 0%); Andrea C Nenzel (corporate director, 0%); Donna King (corporate director, 0%).
- CMS’s Provider of Services file records no change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Peacehealth | Owns 5% or more directly | 100% | Nov 21, 2007 |
| Peacehealth | Runs it (operational or managerial control) | 100% | Nov 21, 2007 |
How does it compare nearby?
- No other hospital CMS lists is in Whatcom County.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.