Cycle 1
Health 2025-03-25 · Fire 2025-03-25
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
25 fire-safety deficiencies
Top issue: Emergency Preparedness (11 deficiencies)
Blaine, WA
Stafholt Health And Rehabilitation Of Cascadia
5-star overall rating with 4-star inspections with $47,182 in total fines with 5 recent health deficiencies with 25 fire-safety deficiencies in the latest cycle
456 C Street, Blaine, WA
(360) 332-8733
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
57
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cascadia Healthcare
Operator or chain grouping
Approved since
1991-09-01
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
1.52
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.34
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.88
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.85
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.54
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
1.37
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.58
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,013
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.76
Composite VBP score used to determine payment impact.
Payment multiplier
0.9909
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.45
Performance 18.91% · Measure score 5.45 · Achievement 5.45 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
6.27
Performance 5.96% · Measure score 6.27 · Achievement 6.27 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Baseline 51.06% · Performance 63.23% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.39
Baseline 4.35 hours · Performance 4.04 hours · Measure score 3.39 · Achievement 3.39 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.52% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 3.92% · Lower 95% interval 5.93% |
| Discharge to community | 54.31% |
50.57%
3.7 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 51.06% · Lower 95% interval 41.74% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.96% |
95.27%
2.7 pts better
|
Numerator 48 · Denominator 49 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 49 |
| Discharge self-care score | 47.37% |
53.69%
6.3 pts worse
|
Numerator 18 · Denominator 38 |
| Discharge mobility score | 39.47% |
50.94%
11.5 pts worse
|
Numerator 15 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 49 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.96% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 34 · Observed rate 0% · Lower 95% interval 2.69% |
| Staff COVID-19 vaccination coverage | 4.55% |
8.2%
3.6 pts worse
|
Numerator 4 · Denominator 88 |
| Staff flu vaccination coverage | 44.33% |
42%
2.3 pts better
|
Numerator 43 · Denominator 97 |
| Discharge function score | 44.74% |
56.45%
11.7 pts worse
|
Numerator 17 · Denominator 38 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 36 · Denominator 36 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | 23.68% |
25.2%
1.5 pts worse
|
Numerator 9 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.0%
4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 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 | 3.6% |
2.6%
1 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 7.0% · Q3 0.0% · Q4 0.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.5% |
16.3%
3.2 pts worse
|
11.4%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 31.7% · Q3 12.5% · Q4 5.0% · 4Q avg 19.5% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.8%
1.1 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.2% · Q3 7.1% · Q4 6.1% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.2% |
12.1%
2.9 pts better
|
19.6%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 9.4% · Q3 7.1% · Q4 8.8% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.6% |
15.9%
1.3 pts better
|
16.7%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 16.1% · Q3 11.1% · Q4 15.6% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.3% |
20.0%
13.7 pts better
|
16.3%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
15.8%
7.1 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 12.5% · Q3 0.0% · Q4 3.0% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.2%
1.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.7%
0.5 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.4% |
23.5%
3.9 pts worse
|
19.8%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 32.4% · Q3 32.0% · Q4 8.0% · 4Q avg 27.4% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
4.7%
3.1 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.4% · Q3 1.2% · Q4 1.4% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
87.7%
10.4 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 98.3% · Q3 100.0% · Q4 97.3% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
13.2%
3.6 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 9.7% · 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 | 93.2% |
82.0%
11.2 pts better
|
79.7%
13.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.1% |
19.9%
3.8 pts better
|
23.9%
7.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 16.1% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-09 · Fire 2024-02-09
23 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
26 fire-safety deficiencies
Top issue: Smoke (10 deficiencies)
Cycle 3
Health 2022-11-04 · Fire 2022-11-04
34 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-25
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
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 2025-04-22
F · Potential for more than minimal harm
2025-03-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-03-25
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-04-22
E · Potential for more than minimal harm
2025-03-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-25
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-22
F · Potential for more than minimal harm
2024-02-09
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-05-01
F · Potential for more than minimal harm
2024-02-09
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-05-01
F · Potential for more than minimal harm
2024-02-09
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-05-01
F · Potential for more than minimal harm
2024-02-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-26
F · Potential for more than minimal harm
2024-02-09
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-01
F · Potential for more than minimal harm
2024-02-09
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-01
F · Potential for more than minimal harm
2024-02-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-01
F · Potential for more than minimal harm
2024-02-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
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 2024-03-12
F · Potential for more than minimal harm
2024-02-09
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 2024-03-12
F · Potential for more than minimal harm
2024-02-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-01
F · Potential for more than minimal harm
2024-02-09
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-09
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 2024-05-01
E · Potential for more than minimal harm
2024-02-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-01
E · Potential for more than minimal harm
2024-02-09
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-05-01
E · Potential for more than minimal harm
2024-02-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-12
E · Potential for more than minimal harm
2024-02-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-02-09
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-02-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-12
F · Potential for more than minimal harm
2022-11-04
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2022-11-22
F · Potential for more than minimal harm
2022-11-04
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2022-11-22
F · Potential for more than minimal harm
2022-11-04
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-12-05
F · Potential for more than minimal harm
2022-11-04
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-11-22
F · Potential for more than minimal harm
2022-11-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-16
F · Potential for more than minimal harm
2022-11-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-15
E · Potential for more than minimal harm
2022-11-04
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-12-05
E · Potential for more than minimal harm
2022-11-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-05
D · Potential for more than minimal harm
2022-11-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-04
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-03-25
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-25
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 2025-05-02
D · Potential for more than minimal harm
2025-03-25
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-25
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-05-02
G · Actual harm
2025-02-10
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 2025-03-07
D · Potential for more than minimal harm
2024-10-02
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 2024-11-01
D · Potential for more than minimal harm
2024-10-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-08-13
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 2024-09-12
D · Potential for more than minimal harm
2024-08-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-13
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-07-23
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 2024-08-31
D · Potential for more than minimal harm
2024-04-04
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 2024-05-07
D · Potential for more than minimal harm
2024-04-04
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-05-07
D · Potential for more than minimal harm
2024-04-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-07
D · Potential for more than minimal harm
2024-04-04
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-05-07
D · Potential for more than minimal harm
2024-02-22
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-07
G · Actual harm
2024-02-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-07
F · Potential for more than minimal harm
2024-02-09
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 2024-05-07
E · Potential for more than minimal harm
2024-02-09
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 2024-05-07
E · Potential for more than minimal harm
2024-02-09
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 2024-05-07
E · Potential for more than minimal harm
2024-02-09
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 2024-05-07
E · Potential for more than minimal harm
2024-02-09
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 2024-05-07
E · Potential for more than minimal harm
2024-02-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-05-07
E · Potential for more than minimal harm
2024-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-07
E · Potential for more than minimal harm
2024-02-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-05-07
D · Potential for more than minimal harm
2024-02-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-05-07
D · Potential for more than minimal harm
2024-02-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-07
D · Potential for more than minimal harm
2024-02-09
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-05-07
D · Potential for more than minimal harm
2023-12-26
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 2024-02-07
D · Potential for more than minimal harm
2023-09-06
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 2023-10-10
D · Potential for more than minimal harm
2023-07-28
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 2023-08-23
D · Potential for more than minimal harm
2023-04-25
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 2023-05-17
D · Potential for more than minimal harm
2023-04-25
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-04-25
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-05-18
F · Potential for more than minimal harm
2022-11-04
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 2023-01-03
F · Potential for more than minimal harm
2022-11-04
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 2023-01-03
F · Potential for more than minimal harm
2022-11-04
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 2023-01-03
E · Potential for more than minimal harm
2022-11-04
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 2023-01-03
E · Potential for more than minimal harm
2022-11-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-01-03
E · Potential for more than minimal harm
2022-11-04
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-01-03
E · Potential for more than minimal harm
2022-11-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-21
D · Potential for more than minimal harm
2022-11-04
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-04
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 2023-01-03
D · Potential for more than minimal harm
2022-11-04
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-04
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 2023-01-03
D · Potential for more than minimal harm
2022-11-04
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-04
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 2023-01-03
D · Potential for more than minimal harm
2022-11-04
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 2023-01-03
D · Potential for more than minimal harm
2022-11-04
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-04
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 2023-01-03
D · Potential for more than minimal harm
2022-11-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-04
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 2023-01-03
D · Potential for more than minimal harm
2022-11-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-04
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-04
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-04
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 2023-01-03
D · Potential for more than minimal harm
2022-11-04
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-04
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-01-03
B · Minimal harm
2022-11-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-01-03
B · Minimal harm
2022-11-04
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-01-03
Penalties and ownership
What sits behind the stars
$32,890
2025-02-10
Fine
Fine · fine $32,890
Fine
$14,292
2023-12-26
Fine
Fine · fine $14,292
Fine
$0
2023-12-26
Payment Denial
Payment Denial · denial start 2024-03-26 · 42 days
42 day denial
Ownership
Blaine 456 Realty, LLC
5% Or Greater Security Interest · Organization
Bristow, Benjamin
Operational/Managerial Control · Individual
Cascadia Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Cascadia Services LLC
Operational/Managerial Control · Organization
Cascadia Washington Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Hammond, Owen
Operational/Managerial Control · Individual
Laforte, Stephen
Operational/Managerial Control · Individual
Nelson, Timothy
Operational/Managerial Control · Individual
St. Germaine, Danielle
Operational/Managerial Control · Individual
White Oak Healthcare Finance LLC
5% Or Greater Security Interest · Organization
Nearby options
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Christian Health Care Center
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5-star overall rating with 4-star inspections with 8 recent health deficiencies with 3 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
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
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