Cycle 1
Health 2025-01-24 · Fire 2025-01-24
25 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Bellingham, WA
North Cascades Health and Rehabilitation
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
4680 Cordata Parkway, Bellingham, WA
(360) 398-1966
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Evergreen Healthcare Group
Operator or chain grouping
Approved since
1991-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
41 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.03
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.83
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.07
CMS adjusted RN staffing hours
Adjusted total hours
3.86
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,782
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9888
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.23
Baseline 17.32% · Performance 19.93% · Measure score 3.23 · Achievement 3.23 · Improvement 0
Healthcare-associated infections
4.20
Baseline 3.81% · Performance 6.58% · Measure score 4.20 · Achievement 4.20 · Improvement 0
Total nurse turnover
3.92
Baseline 65.00% · Performance 47.67% · Measure score 3.92 · Achievement 3.92 · Improvement 3.82
Adjusted total nurse staffing
2.68
Baseline 3.78 hours · Performance 3.84 hours · Measure score 2.68 · Achievement 2.68 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.47% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 237 · Observed rate 8.02% · Lower 95% interval 6.42% |
| Discharge to community | 59.34% |
50.57%
8.8 pts better
|
Better than the National Rate · Eligible stays 220 · Observed rate 55.91% · Lower 95% interval 55.09% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.64% |
95.27%
3.4 pts better
|
Numerator 145 · Denominator 147 |
| Falls with major injury | 0.68% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 147 |
| Discharge self-care score | 50.47% |
53.69%
3.2 pts worse
|
Numerator 54 · Denominator 107 |
| Discharge mobility score | 41.12% |
50.94%
9.8 pts worse
|
Numerator 44 · Denominator 107 |
| Pressure ulcers or injuries, new or worsened | 0.68% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 147 · Adjusted rate 0.85% |
| Healthcare-associated infections requiring hospitalization | 6.58% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 145 · Observed rate 5.52% · Lower 95% interval 3.93% |
| Staff COVID-19 vaccination coverage | 24.06% |
8.2%
15.9 pts better
|
Numerator 32 · Denominator 133 |
| Staff flu vaccination coverage | 79.22% |
42%
37.2 pts better
|
Numerator 122 · Denominator 154 |
| Discharge function score | 61.68% |
56.45%
5.2 pts better
|
Numerator 66 · Denominator 107 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 41 · Denominator 41 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 75 · Denominator 75 |
| Resident COVID-19 vaccinations up to date | 7.89% |
25.2%
17.3 pts worse
|
Numerator 6 · Denominator 76 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.4
0.4 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
96.0%
2.4 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 98.5% · Q3 98.3% · Q4 98.4% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
93.8%
4.8 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
2.6%
0.2 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.1% · Q3 1.7% · Q4 1.6% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.9% |
16.3%
9.4 pts better
|
11.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.9% · Q3 3.7% · Q4 20.8% · 4Q avg 6.9% |
| Percentage of long-stay residents who lose too much weight | 8.6% |
5.8%
2.8 pts worse
|
5.4%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 7.5% · Q3 7.8% · Q4 9.4% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.2% |
12.1%
1.9 pts better
|
19.6%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 7.4% · Q3 9.6% · Q4 14.8% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.7% |
15.9%
5.8 pts worse
|
16.7%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 22.5% · Q3 25.0% · Q4 24.4% · 4Q avg 21.7% · 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 | 5.3% |
20.0%
14.7 pts better
|
16.3%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 4.6% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
15.8%
5.5 pts better
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 11.1% · Q3 9.8% · Q4 5.6% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.2%
0.3 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.7%
0.5 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.6% · Q3 0.0% · Q4 1.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.1% |
23.5%
4.4 pts better
|
19.8%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 21.5% · Q3 21.0% · Q4 18.8% · 4Q avg 19.1% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
4.7%
3.2 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.4% · Q3 0.0% · Q4 1.4% · 4Q avg 1.5% · 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 95.5% · Q2 97.8% · Q3 96.9% · Q4 96.4% · 4Q avg 96.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
13.2%
7.2 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.7% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.4%
0.8 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.2% · Q3 2.0% · Q4 1.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.1% |
82.0%
13.1 pts better
|
79.7%
15.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.3% |
19.9%
7.4 pts worse
|
23.9%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.3% · Observed 24.1% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-08 · Fire 2024-03-08
26 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Cycle 3
Health 2023-06-09 · Fire 2023-06-09
42 health deficiencies
Top issue: Quality of Life and Care (13 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-24
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-01-31
F · Potential for more than minimal harm
2025-01-24
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-01-31
F · Potential for more than minimal harm
2025-01-24
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-01-31
F · Potential for more than minimal harm
2025-01-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-31
E · Potential for more than minimal harm
2025-01-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-03-08
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-03-08
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-03-08
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-03-08
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-03-08
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-03-08
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-03-08
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-03-08
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-03-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-03-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-03-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-03-08
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 2024-04-08
D · Potential for more than minimal harm
2024-03-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-08
F · Potential for more than minimal harm
2023-06-09
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-07-06
F · Potential for more than minimal harm
2023-06-09
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2023-07-06
F · Potential for more than minimal harm
2023-06-09
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-07-06
F · Potential for more than minimal harm
2023-06-09
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-07-06
F · Potential for more than minimal harm
2023-06-09
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-06-09
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-06-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-06-09
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-06-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-06-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-06-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-06
Inspection history
Recent health citations
G · Actual harm
2026-01-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-09
G · Actual harm
2026-01-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-02-09
D · Potential for more than minimal harm
2026-01-28
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2026-02-09
D · Potential for more than minimal harm
2026-01-28
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2026-02-09
D · Potential for more than minimal harm
2026-01-28
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 2026-02-09
E · Potential for more than minimal harm
2025-12-17
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-12-17
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-12-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-12-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-12-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-03-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-28
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-14
J · Immediate jeopardy
2025-01-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-01-24
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-01-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-24
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 2025-02-21
D · Potential for more than minimal harm
2025-01-24
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 2025-02-21
D · Potential for more than minimal harm
2025-01-24
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 2025-02-21
D · Potential for more than minimal harm
2025-01-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-24
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-24
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 2025-02-21
D · Potential for more than minimal harm
2025-01-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-24
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 2025-02-21
D · Potential for more than minimal harm
2025-01-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-21
D · Potential for more than minimal harm
2024-12-30
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-01-13
E · Potential for more than minimal harm
2024-09-05
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 2024-10-04
D · Potential for more than minimal harm
2024-09-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-12
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-09-03
G · Actual harm
2024-06-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-06-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-20
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 2024-07-15
D · Potential for more than minimal harm
2024-04-17
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
2024-04-17
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-06
G · Actual harm
2024-03-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-18
F · Potential for more than minimal harm
2024-03-08
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-04-18
F · Potential for more than minimal harm
2024-03-08
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-04-18
E · Potential for more than minimal harm
2024-03-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-18
E · Potential for more than minimal harm
2024-03-08
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-04-18
E · Potential for more than minimal harm
2024-03-08
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 2024-04-18
E · Potential for more than minimal harm
2024-03-08
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 2024-04-18
D · Potential for more than minimal harm
2024-03-08
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 2024-04-18
D · Potential for more than minimal harm
2024-03-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-08
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 2024-04-18
D · Potential for more than minimal harm
2024-03-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-08
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 2024-04-18
D · Potential for more than minimal harm
2024-03-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-08
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 2024-04-18
D · Potential for more than minimal harm
2024-03-08
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 2024-04-18
D · Potential for more than minimal harm
2024-03-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-18
G · Actual harm
2023-12-21
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 2024-01-19
G · Actual harm
2023-12-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-19
F · Potential for more than minimal harm
2023-12-21
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 2024-01-19
F · Potential for more than minimal harm
2023-12-21
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 2024-01-19
F · Potential for more than minimal harm
2023-12-21
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-12-21
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-12-21
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 2024-01-19
E · Potential for more than minimal harm
2023-12-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-21
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 2024-01-19
D · Potential for more than minimal harm
2023-11-13
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 2023-12-21
D · Potential for more than minimal harm
2023-11-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-10-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-07
D · Potential for more than minimal harm
2023-10-30
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 2023-12-07
D · Potential for more than minimal harm
2023-10-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-07
G · Actual harm
2023-09-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-13
E · Potential for more than minimal harm
2023-09-19
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 2023-10-13
G · Actual harm
2023-06-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-26
G · Actual harm
2023-06-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-06-09
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2023-07-26
E · Potential for more than minimal harm
2023-06-09
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 2023-07-26
E · Potential for more than minimal harm
2023-06-09
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 2023-07-26
E · Potential for more than minimal harm
2023-06-09
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 2023-07-26
D · Potential for more than minimal harm
2023-06-09
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 2023-07-26
D · Potential for more than minimal harm
2023-06-09
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 2023-07-26
D · Potential for more than minimal harm
2023-06-09
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-09
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 2023-07-26
D · Potential for more than minimal harm
2023-06-09
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-09
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 2023-07-26
D · Potential for more than minimal harm
2023-06-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-09
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 2023-07-26
D · Potential for more than minimal harm
2023-06-09
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-09
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-26
B · Minimal harm
2023-06-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-04-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-09
G · Actual harm
2023-03-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-02
E · Potential for more than minimal harm
2023-03-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-05-02
D · Potential for more than minimal harm
2023-03-22
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 2023-05-02
D · Potential for more than minimal harm
2023-03-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-02
Penalties and ownership
What sits behind the stars
$15,584
2024-12-30
Fine
Fine · fine $15,584
Fine
$50,278
2024-06-20
Fine
Fine · fine $50,278
Fine
$104,832
2024-03-08
Fine
Fine · fine $104,832
Fine
$46,449
2023-09-19
Fine
Fine · fine $46,449
Fine
$77,074
2023-06-09
Fine
Fine · fine $77,074
Fine
$52,826
2023-03-22
Fine
Fine · fine $52,826
Fine
Ownership
Ch Pacific Northwest Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Witzcorp Global LLC
5% Or Greater Indirect Ownership Interest · Organization
Chua, Winnie
Operational/Managerial Control · Individual
Couve Financial Services LLC
Operational/Managerial Control · Organization
Couve Healthcare Consulting LLC
Operational/Managerial Control · Organization
Giltner, Kody
Operational/Managerial Control · Individual
Johnson, Allen
Operational/Managerial Control · Individual
Odenthal, Jason
Operational/Managerial Control · Individual
Pacific Northwest Opco Management LLC
Operational/Managerial Control · Organization
Servoss, Kyle
Operational/Managerial Control · Individual
Spielman, Shimon
Operational/Managerial Control · Individual
Washington SNF Consulting LLC
Operational/Managerial Control · Organization
Yenowitz, Yitzchok
Operational/Managerial Control · Individual
Nearby options
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Alderwood Park Health And Rehab Of Cascadia
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
#2
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
#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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