12 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Bellingham, WA
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
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
Staffing
RN hours / resident day
0.93
Registered nurse staffing
LPN hours / resident day
0.76
Licensed practical nurse staffing
Aide hours / resident day
2.12
Nurse aide staffing
Weekend hours
3.21
Weekend nurse staffing
RN turnover
35%
Annual RN turnover
Total nurse turnover
41%
Annual nurse turnover
Quality measures
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 28.2% |
20.0%
8.2 pts worse
|
16.3%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Top issue: Pharmacy Service (3 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Top issue: Administration (6 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-03-30
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2025-03-30
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-03-30
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-03-30
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-30
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
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-30
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-30
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-30
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-30
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-03-30
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-30
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-04-15
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-05-09
Fire Safety
Develop a communication plan.
Corrected 2024-04-15
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-04-15
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-05-09
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-04-15
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-05-09
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-01
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-15
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-15
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-01-06
Fire Safety
Develop a communication plan.
Corrected 2023-01-06
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-01-06
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-01-06
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-01-06
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-06
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-06
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
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-01-06
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-01-06
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-06
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-06
Inspection history
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
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
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
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
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
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-21
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-21
Health
Post nurse staffing information every day.
Corrected 2025-04-21
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
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
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
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-04-21
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-22
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-25
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-07-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-05
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
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-05-06
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
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
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-06
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
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
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-06
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-06
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
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-06
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-05-06
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-06
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
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-06
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
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
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
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
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-05
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
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-05
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-23
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-05-23
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2023-05-23
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-05-23
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-23
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-23
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2023-05-23
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
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
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
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-01-17
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-17
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
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-17
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
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-17
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-01-17
Health
Provide or obtain dental services for each resident.
Corrected 2023-01-17
Health
Post nurse staffing information every day.
Corrected 2023-01-17
Penalties and ownership
Fine · fine $52,574
Fine
5% Or Greater Security Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Security Interest · Organization
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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
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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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