Cycle 1
Health 2025-02-28 · Fire 2025-02-28
12 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Bellingham, WA
Alderwood Park Health And Rehab Of Cascadia
3-star overall rating with 2-star inspections with $52,574 in total fines with 12 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
2726 Alderwood Avenue, Bellingham, WA
(360) 733-2322
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
102
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cascadia Healthcare
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
44 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
0.93
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
35%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,497
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9855
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.22
Baseline 19.18% · Performance 19.48% · Measure score 4.22 · Achievement 4.22 · Improvement 0
Healthcare-associated infections
5.93
Baseline 5.11% · Performance 6.06% · Measure score 5.93 · Achievement 5.93 · Improvement 0
Total nurse turnover
1.33
Performance 58.23% · Measure score 1.33 · Achievement 1.33 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.35
Baseline 2.78 hours · Performance 3.04 hours · Measure score 0.35 · Achievement 0 · Improvement 0.35
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.43% |
10.72%
2.3 pts better
|
No Different than the National Rate · Eligible stays 169 · Observed rate 4.73% · Lower 95% interval 6.48% |
| Discharge to community | 51.43% |
50.57%
0.9 pts better
|
No Different than the National Rate · Eligible stays 171 · Observed rate 47.37% · Lower 95% interval 43.78% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.1% |
95.27%
2.8 pts better
|
Numerator 155 · Denominator 158 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 158 |
| Discharge self-care score | 30.09% |
53.69%
23.6 pts worse
|
Numerator 34 · Denominator 113 |
| Discharge mobility score | 43.36% |
50.94%
7.6 pts worse
|
Numerator 49 · Denominator 113 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 158 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.06% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 140 · Observed rate 4.29% · Lower 95% interval 3.57% |
| Staff COVID-19 vaccination coverage | 4.67% |
8.2%
3.5 pts worse
|
Numerator 5 · Denominator 107 |
| Staff flu vaccination coverage | 47.41% |
42%
5.4 pts better
|
Numerator 55 · Denominator 116 |
| Discharge function score | 46.9% |
56.45%
9.6 pts worse
|
Numerator 53 · Denominator 113 |
| Transfer of health information to provider | 98.95% |
95.95%
3 pts better
|
Numerator 94 · Denominator 95 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 33.75% |
25.2%
8.6 pts better
|
Numerator 27 · Denominator 80 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.4
0.5 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| 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 | 100.0% |
93.8%
6.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
2.6%
0.3 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 3.8% · Q4 3.6% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 44.7% |
16.3%
28.4 pts worse
|
11.4%
33.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.2% · Q2 53.8% · Q3 41.7% · Q4 38.9% · 4Q avg 44.7% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
5.8%
0.7 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 2.2% · Q3 4.8% · Q4 4.5% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.1% |
12.1%
20 pts worse
|
19.6%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.7% · Q2 37.0% · Q3 34.9% · Q4 21.7% · 4Q avg 32.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.4% |
15.9%
8.5 pts better
|
16.7%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 7.9% · Q3 8.3% · Q4 4.9% · 4Q avg 7.4% · 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 | 28.2% |
20.0%
8.2 pts worse
|
16.3%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.6% |
15.8%
1.8 pts worse
|
14.9%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 20.9% · Q3 12.5% · Q4 21.4% · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.2%
0.4 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.7%
0.7 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 2.0% · Q4 3.8% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.6% |
23.5%
9.1 pts worse
|
19.8%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.6% · Q2 40.8% · Q3 23.3% · Q4 26.6% · 4Q avg 32.6% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.7%
2.4 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.1% · Q3 2.9% · Q4 1.9% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
87.7%
11.2 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 99.1% · Q3 99.2% · Q4 99.2% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.7% |
13.2%
4.5 pts better
|
12.0%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.7% · Observed 8.7% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.4%
1.4 pts better
|
1.6%
1.6 pts better
|
Short 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 who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
82.0%
14.4 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
19.9%
2.6 pts worse
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 21.7% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-26 · Fire 2024-03-26
20 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Cycle 3
Health 2022-12-09 · Fire 2022-12-09
25 health deficiencies
Top issue: Administration (6 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-28
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-03-30
F · Potential for more than minimal harm
2025-02-28
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2025-03-30
F · Potential for more than minimal harm
2025-02-28
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-03-30
F · Potential for more than minimal harm
2025-02-28
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-03-30
F · Potential for more than minimal harm
2025-02-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-30
E · Potential for more than minimal harm
2025-02-28
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-03-30
D · Potential for more than minimal harm
2025-02-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-30
D · Potential for more than minimal harm
2025-02-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-30
D · Potential for more than minimal harm
2025-02-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-30
D · Potential for more than minimal harm
2025-02-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-30
D · Potential for more than minimal harm
2025-02-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-30
D · Potential for more than minimal harm
2025-02-28
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-03-30
D · Potential for more than minimal harm
2025-02-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-30
F · Potential for more than minimal harm
2024-03-26
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-03-26
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-05-09
F · Potential for more than minimal harm
2024-03-26
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-03-26
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-03-26
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-05-09
F · Potential for more than minimal harm
2024-03-26
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-03-26
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-05-09
F · Potential for more than minimal harm
2024-03-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-03-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-01
F · Potential for more than minimal harm
2024-03-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-03-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-15
F · Potential for more than minimal harm
2022-12-09
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-12-09
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-12-09
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-12-09
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-12-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-12-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-12-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-12-09
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 2023-01-06
F · Potential for more than minimal harm
2022-12-09
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-12-09
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-12-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-12-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-06
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-28
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-04-21
E · Potential for more than minimal harm
2025-02-28
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 2025-04-21
E · Potential for more than minimal harm
2025-02-28
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-21
E · Potential for more than minimal harm
2025-02-28
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-04-21
E · Potential for more than minimal harm
2025-02-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-21
E · Potential for more than minimal harm
2025-02-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-02-28
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 2025-04-21
D · Potential for more than minimal harm
2025-02-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-02-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-02-28
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 2025-04-21
D · Potential for more than minimal harm
2025-02-28
F761 · Pharmacy Service Deficiencies
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 2025-04-21
D · Potential for more than minimal harm
2025-02-28
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-01-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-10-28
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 2024-11-25
D · Potential for more than minimal harm
2024-05-29
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 2024-07-05
D · Potential for more than minimal harm
2024-05-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-05
F · Potential for more than minimal harm
2024-03-26
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 2024-05-06
E · Potential for more than minimal harm
2024-03-26
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-05-06
E · Potential for more than minimal harm
2024-03-26
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-05-06
E · Potential for more than minimal harm
2024-03-26
F625 · Resident Rights Deficiencies
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 2024-05-06
E · Potential for more than minimal harm
2024-03-26
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 2024-05-06
D · Potential for more than minimal harm
2024-03-26
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 2024-05-06
D · Potential for more than minimal harm
2024-03-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-03-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-03-26
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-03-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-03-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-03-26
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-03-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-03-26
F761 · Pharmacy Service Deficiencies
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 2024-05-06
D · Potential for more than minimal harm
2024-03-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-03-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-02
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-23
D · Potential for more than minimal harm
2023-08-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-08-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-07-31
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-07-31
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-07-31
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-05
J · Immediate jeopardy
2023-04-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-23
F · Potential for more than minimal harm
2023-04-24
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-05-23
E · Potential for more than minimal harm
2023-04-24
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2023-05-23
E · Potential for more than minimal harm
2023-04-24
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-24
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-24
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-05-23
F · Potential for more than minimal harm
2022-12-09
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-01-17
E · Potential for more than minimal harm
2022-12-09
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 2023-01-17
E · Potential for more than minimal harm
2022-12-09
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 2023-01-17
E · Potential for more than minimal harm
2022-12-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-17
D · Potential for more than minimal harm
2022-12-09
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 2023-01-17
D · Potential for more than minimal harm
2022-12-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-17
D · Potential for more than minimal harm
2022-12-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-01-17
D · Potential for more than minimal harm
2022-12-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-17
D · Potential for more than minimal harm
2022-12-09
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-01-17
D · Potential for more than minimal harm
2022-12-09
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-01-17
B · Minimal harm
2022-12-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-01-17
Penalties and ownership
What sits behind the stars
$52,574
2023-04-24
Fine
Fine · fine $52,574
Fine
Ownership
Bellingham 2726 Realty, LLC
5% Or Greater Security Interest · Organization
Cascadia Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Cascadia Services LLC
Operational/Managerial Control · Organization
Dhaliwal, Navdeep
Operational/Managerial Control · Individual
Hammond, Owen
Operational/Managerial Control · Individual
Laforte, Stephen
Operational/Managerial Control · Individual
Nelson, Timothy
Operational/Managerial Control · Individual
Rudd, Joseph
Operational/Managerial Control · Individual
White Oak Healthcare Finance LLC
5% Or Greater Security Interest · Organization
Nearby options
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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
#2
North Cascades Health and Rehabilitation
Bellingham, WA
2-star overall rating with 1-star inspections with $347,043 in total fines with 25 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
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
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