Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alderwood Park Health And Rehab Of Cascadia during CMS and state inspections, most recent first.
Incomplete grievance investigation and resolution: Facility grievance records were missing key elements such as the grievance summary, investigation steps, confirmation status, written resolution, and follow-up with the resident to determine satisfaction. Residents in council interviews reported no follow-up, no written feedback, and no interviews about their concerns, while staff acknowledged the documentation did not show that the grievance process was being followed.
Restorative nursing services were not provided as care planned for several residents with limited ROM and mobility needs. A resident with hemiplegia had a care planned ROM and sit-to-stand program, but documentation showed minimal participation and no monitoring, while observations found the arm dangling, discolored, and painful with finger contracture. Other residents with spinal stenosis, pelvic fracture, cerebral palsy, and muscle weakness also reported receiving restorative exercises only sporadically or not at all, and staff confirmed some programs were not being implemented or were incorrectly entered in the record.
A resident with a positive PASRR Level 2 for ID had no documented evaluation of the specialized services required and no individualized care plan reflecting the PASRR findings. The record showed the resident had right-sided hemiplegia and ESRD on dialysis, while staff interviews confirmed they relied on the care plan, were unaware of the resident’s intellectual delay or related condition, and had no documentation of the Level 2 recommendations in the chart.
A resident with cognitive impairment, prior nerve injury, paralysis of the L arm, and a severe L hand contracture had an incomplete care plan that addressed skin integrity only in general terms and did not include specific contracture-related goals or interventions. Staff reported the resident was resistant to hand care and that they were supposed to offer nail care, clean inside the hand, and document refusals, but the record lacked clear documentation of the hand condition, accepted care, or refusals; the resident was observed with a severely contracted, calloused hand and overgrown nails.
A resident with Parkinson’s disease, dementia, and malnutrition had significant cognitive impairment and required partial to moderate assist with eating, but staff did not consistently provide supervision, verbal cues, or hands-on help during meals. The care plan and Kardex were unclear about what to do if finger foods were not provided and did not clearly address snacks or alternatives when less than 50% of a meal was eaten. The resident lost 8.73% of body weight in less than a month, and staff were unsure how to document meal intake, snacks, alternatives, or POA notification of the weight loss.
The facility failed to provide respiratory care consistent with orders and professional standards for three residents with OSA and other respiratory conditions. One resident with COPD and chronic respiratory failure was repeatedly observed without O2 on, with the concentrator off and the BiPAP/CPAP out of reach, while the record showed oxygen saturations were not routinely monitored and the resident reported the device was not cleaned or reliably applied at night. Two other residents had CPAP orders and care plans that did not address vendor information, manufacturer guidance, replacement timing, or humidifier cleaning, and staff gave inconsistent accounts of CPAP cleaning and part replacement responsibilities.
Staff failed to follow infection control practices during wound care for one resident with a wound vac, including not disinfecting the overbed table, handling supplies after they touched the floor, and changing gloves without hand hygiene. Staff also did not follow EBP for another resident with chronic wounds; no signage or PPE bin was present, and staff did not use gown and gloves during care despite orders and documentation indicating EBP were required.
The facility failed to honor the preferences of several residents regarding their daily schedules and bathing routines. A resident with severe cognitive impairment was left in their wheelchair for almost an hour after requesting to lay down. Another resident, who preferred showers twice a week, received bed baths instead due to a misunderstanding about their wound VAC. Additional residents experienced delays and inconsistencies in their bathing schedules, highlighting a lack of coordination among staff to ensure resident choices are respected.
The facility failed to maintain a safe environment by not ensuring the availability and condition of transfer slings, addressing gouges in flooring, and ensuring call lights were functional and accessible. Observations revealed damaged slings in use, flooring in disrepair, and call lights not within reach or audible for residents, including those with mobility issues. Staff interviews confirmed these ongoing issues, compromising resident safety and care.
The facility failed to update care plans for three residents, leading to potential risks for unmet care needs. A resident with poor eyesight did not have adequate assistance documented, and their fall mat alarm was not properly positioned. Another resident with a catheter and pressure ulcers lacked documented peri-care and repositioning, and their care plan did not reflect current needs. A third resident's care plan inaccurately listed a discontinued medication. These deficiencies highlight ongoing issues with care plan management.
The facility failed to provide adequate staffing, resulting in delayed responses to call lights and assistance with daily activities. Residents and family members reported long wait times for care, and staffing data showed consistently low weekend staffing levels. Despite attempts to staff according to census and acuity, the facility faced challenges due to call-outs and staff turnover, operating below the allotted nursing service hours.
The facility failed to maintain complete and accurate medical records for four residents, including missing hospice notes, lab results, and blood sugar monitoring. Limited access to the hospice's electronic record system and incomplete documentation of vital signs and care tasks contributed to these deficiencies, placing residents at risk for medical complications.
The facility failed to comply with infection control guidelines, as observed in medication administration, transmission-based precautions, and catheter care. An LPN did not perform hand hygiene or wear PPE while administering insulin. Staff did not adhere to droplet precautions for a resident with RSV, and hand hygiene lapses were noted during catheter care. The facility's infection preventionist and DON were unaware of these issues.
The facility failed to provide necessary assistance for oral care and bathing for three residents dependent on staff. A resident reported receiving only two showers and one bed bath since admission, despite needing extensive assistance. Another resident, totally dependent on staff, received only one shower and one bed bath. A third resident, requiring assistance with oral care, did not receive help with denture removal and cleaning. The DON was unaware of these issues, and there was no shower policy in place.
The facility did not post daily nurse staffing information in an accessible location for two days during a survey. The posted information was outdated and incomplete, lacking updates for the evening and night shifts. The Staffing Coordinator, responsible for the postings, was unaware of the missing information, and the DON confirmed the oversight.
The facility failed to accurately reconcile controlled medications in one of the medication carts. A discrepancy was found when a nurse discovered that the narcotic book indicated remaining tablets, but none were present in the cart. The issue arose because licensed nurses did not sign out the last doses in the narcotic book, although they documented administration in the MAR. The Director of Nursing confirmed the expectation for nurses to check the narcotic book for accuracy and report discrepancies.
The facility failed to ensure proper medication management and storage, with unlocked medication carts and unsecured controlled substances. Expired medications and vaccines were found, indicating lapses in monitoring. Staff interviews revealed gaps in responsibility and knowledge regarding medication storage requirements.
The facility failed to provide timely lab results for two residents, leading to potential complications. One resident experienced delays in UTI testing, while another faced issues with stool sample processing. Staff expressed concerns about the contracted lab's reliability and were seeking local services to improve turnaround times.
A resident with COPD and sleep apnea had their CPAP machine brought into the facility, but the staff failed to obtain a physician order for its use and did not perform routine cleaning. The resident's care plan did not include the CPAP machine, and staff were unaware of its presence, leading to a deficiency in respiratory care.
A resident with multiple diagnoses, including schizophrenia and muscle weakness, did not receive adequate assistance with ADLs in an LTC facility. The resident was left without proper meal assistance, as caregiver agency staff arrived late, and incontinence care was inconsistent, with the resident found soaked in urine. The facility's care plan was outdated, leading to a lack of coordination in the resident's care.
The facility failed to provide adequate assistance with activities of daily living, including personal hygiene and bathing, for two residents who were dependent on staff. One resident received only two baths in 17 days, while another received only one bed bath in two weeks. Observations and interviews revealed that both residents had food remnants on their bodies and expressed dissatisfaction with their hygiene care.
The facility failed to manage a resident's constipation according to physician orders and bowel protocol. The resident experienced multiple periods without a bowel movement, refused medications, and there was no documentation that the provider was notified. This deficiency was a repeat citation from previous surveys.
Incomplete Grievance Investigation and Resolution
Penalty
Summary
The facility failed to ensure thorough investigation and resolution of resident grievances for one resident group, with grievance records showing incomplete documentation of the summary of the grievance, steps taken to investigate, whether the grievance was confirmed or not confirmed, written resolution, and communication with the person making the grievance to determine whether the resolution was satisfactory. The facility grievance policy stated the Nursing Home Administrator or designee was responsible for tracking and concluding grievances, but review of the grievance logs for the prior six months showed multiple grievances, including resident council concerns about communication, care, missing items, and dietary issues, with dietary grievances later being placed on an ongoing grievance form rather than being individually logged. During a resident council interview, residents stated they were not receiving follow-up or written summaries of what was done about their grievances, and one resident said they never got interviewed about their concerns. Another resident stated they did not know whether grievances had been seen and that nothing changed, while another said they never heard back about grievances. Staff C stated grievances were routed to the involved department, discussed as a team, and kept in social services, and acknowledged the current grievance forms were not showing that the process was being followed. Staff A stated grievances were reviewed in stand-up meetings and assignments were made, but the paperwork remained with social services and residents were not being provided copies of grievance resolutions.
Restorative Nursing Services Not Provided as Care Planned
Penalty
Summary
The facility failed to ensure that five residents with limited ROM and mobility needs received the restorative nursing services that were care planned or recommended. The report states that the facility did not ensure residents received appropriate restorative nursing services programs as ordered, and that the failure placed residents at risk for decline in mobility and function, increased dependence on staff, and a decreased quality of life. Resident 3 was admitted with right-sided hemiplegia and end stage renal disease requiring dialysis. The care plan directed restorative nursing for decline in mobility, ROM, physical weakness, and risk for contractures, including passive/active assist ROM to the elbow, shoulder, and wrist and sit-to-stand exercises several times per week. However, restorative documentation showed the program was offered only a few times over several months, with refusals and limited participation, and progress notes did not show monitoring, refusal follow-up, or assessment of the restorative program. During observations, the resident’s right arm and hand were dangling, discolored, and the right fingers were partially curled closed; the resident stated the hand was painful when straightened. Staff interviews showed the restorative program was not being consistently offered and that the resident had not really been worked with because of room moves and dialysis schedules. Resident 9 had spinal stenosis, muscle wasting, and atrophy. Therapy had established a restorative program for bilateral lower extremity exercises, and the care plan directed restorative nursing to maintain strength and ROM several times per week. The resident stated staff did not move them enough, did not turn them enough, and that they did not receive restorative after therapy ended. Survey observations over multiple days did not show the resident receiving restorative services, and the clinical record did not show the ordered restorative program being provided. Staff later stated the resident did not have a restorative program, and the DNS acknowledged the order had been incorrectly placed under the goal portion of the care plan so the resident had not received restorative services yet. Resident 4, Resident 16, and Resident 26 also had care planned restorative programs that were not provided as ordered. Resident 4, with pelvic fracture, kyphosis, muscle weakness, and difficulty walking, was supposed to receive bed mobility and sit-to-stand restorative exercises three to six times per week, but the resident reported only getting exercise about twice a week and staff confirmed the program was not being completed at the ordered frequency. Resident 16, with quadriplegic cerebral palsy, muscle weakness, and osteoarthritis, was care planned for PROM to upper and lower extremities three to six times per week, but the record did not show the program and the resident reported it was received sporadically. Resident 26, with spinal stenosis, spondylosis, weakness, and muscle wasting, was care planned for PROM and active assist exercises three to six times per week, but the record did not show the program and the resident reported receiving it only once or twice a week. Staff interviews indicated the restorative programs were not being consistently supervised or documented as required.
PASRR Level 2 Evaluation Not Reflected in Care Plan
Penalty
Summary
The facility failed to ensure that Resident 3, who had a positive Level 1 PASRR requiring a Level 2 evaluation for intellectual disability, had the Level 2 determination incorporated into the resident’s record and care planning. The facility policy stated that positive Level 1 screens would require an in-depth evaluation and that recommendations would be incorporated into the plan of care. Resident 3 was admitted with diagnoses including right-sided hemiplegia and end stage renal disease with dialysis dependence, and the Quarterly MDS documented intact cognition, moderate depression, and no refusal of care. Review of the PASRR documents showed a Level 1 screen dated 08/21/2025 requiring a Level 2 evaluation for ID, and a Level 2 determination letter dated 08/14/2025 stating the resident did have an intellectual disability or related condition, met the requirements for nursing facility care, and required new specialized services. However, the medical record contained no evaluation of what services the resident qualified for or required based on that determination. The care plan focused on impaired cognitive function/dementia or impaired thought process related to developmental delay, but the interventions were not specific to Resident 3 and did not mention the positive PASRR Level 2 or individualized services. Progress notes from admission through 01/12/2026 contained no documentation that the facility reviewed or inquired about the specialized services associated with the Level 2 PASRR determination. During observations on 01/13/2026, 01/14/2026, and 01/15/2026, Resident 3 was noted with disheveled hair, unkempt facial hair, dirty or stained clothing, and food on the blankets and clothing. Staff interviews showed nursing assistants relied on the care plan, were unaware of the resident’s intellectual delay or related condition, and treated the resident’s staying in a wheelchair and declining care as refusal. An RN was also unaware of the resident’s intellectual delay or related condition, and Social Services and leadership stated they were trying to obtain services but confirmed there was no documentation of the Level 2 evaluation being received or any recommendations for care.
Incomplete Care Planning and Documentation for Contracted Hand
Penalty
Summary
Comprehensive care planning and implementation were not completed for a resident with cognitive impairment, a prior fall with nerve injury and paralysis of the left arm, and a severe contracture of the left hand. During observation, the resident was seen self-propelling in a wheelchair by pulling with the feet and using the right hand, while the left hand was severely contracted in a fisted position with thick calloused skin and nails grown in a curved, long manner. In interview, the resident stated the hand had curled up after the fall and said they either needed it amputated or would have to live with it, adding that staff did not touch it and that only the doctor could touch it. Record review showed the annual MDS documented no behaviors or refusals of care. The care plan for skin integrity, dated 07/25/2022, identified risk for altered skin integrity due to impaired mobility and left hand contracture, but the goal of intact skin did not include specific goals related to the contracture or the associated risk, and the interventions included nail care only, with no contracture care or hand-specific care. Weekly skin audit documentation in the TAR showed only initials and a checkmark, without the expected Y/N documentation, progress notes about the left hand condition, or documentation that the resident accepted or refused hand care. Staff stated they were supposed to offer nail care, attempt to clean inside the hand, monitor, and document, but also stated the resident became agitated or aggressive when hand care was attempted and was resistant.
Meal Assistance and Nutrition Documentation Failure
Penalty
Summary
The facility failed to consistently provide supervision, verbal cues, or assistance with meals according to the resident’s individualized assessments and plan of care, and it did not develop a process to document whether supplements, alternative meals, or snacks were offered. Resident 58 was admitted with Parkinson’s disease, unspecified protein-calorie malnutrition, need for assistance with personal care, and dementia. The resident’s admission MDS showed a BIMS score of 03, indicating significant cognitive impairment, and the assessment also showed partial to moderate assistance with eating. A Mini Nutritional Assessment documented malnutrition, moderate decrease in food intake, difficulty feeding self, and a preference for finger foods. The care plan identified the resident as at risk for nutritional decline due to decreased ability to use utensils and stated that if the resident consumed less than 50% of a meal, a snack or alternative would be offered. The ADL care plan and Kardex documented supervision or touch assistance for eating finger foods with verbal cues, but neither included instructions for what assistance was needed if the resident was not provided finger foods or for snacks or alternatives if less than 50% of the meal was eaten. During continuous observation on two mornings, the resident was seen seated in a wheelchair with breakfast in front of them while staff set up the meal and left the room, with no supervision, verbal cues, or assistance provided. The resident’s weights showed a decrease from 207.4 lbs. to 189.3 lbs. in 24 days, an 8.73% loss. Staff interviews showed uncertainty about how to provide and document meal assistance, snacks, or alternatives, and the CNO confirmed the care plan was unclear regarding assistance if the resident was not provided finger foods. The spouse/POA stated the resident needed help to eat, preferred to eat in the room, and believed the resident had lost weight, but was unaware of any notification about the weight loss. The CNO also confirmed there was no documentation that the POA had been notified of the weight loss.
Respiratory Care and CPAP Management Not Provided Consistently
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for three residents who had orders and histories related to OSA and oxygen therapy. The report states that the facility did not ensure oxygen delivery was provided per physician order, did not routinely monitor or assess resident responses to oxygen therapy, and did not ensure ordered CPAP equipment was in place when required. The report also states that CPAP equipment was not cleaned and parts were not replaced according to manufacturer recommendations. One resident with COPD, OSA, and chronic respiratory failure had a history of requesting a CPAP after the prior device had been taken away. A referral to pulmonology was sent, but the record showed no further follow-up until a BiPAP machine was dropped off months later. Physician orders later included continuous oxygen at 2 L/min by nasal cannula and BiPAP use at night. The resident’s care plan did not address the BiPAP vendor, contact information, brand, manufacturer guidelines, replacement schedule, or humidifier chamber cleaning. During multiple observations, the resident was found in bed without oxygen on, with the oxygen concentrator at the foot of the bed in the off position, and the BiPAP at bedside without a filter. The resident stated staff had not cleaned the machine, had not checked the water level, and had not consistently put the CPAP/BiPAP on at night. The resident also stated oxygen saturations were rarely checked, and the record showed oxygen saturations were not routinely monitored. Two other residents with OSA also had CPAP-related orders and care plans that did not address the CPAP supply vendor, contact information, brand, manufacturer guidelines, replacement timing, or humidifier chamber cleaning. One resident had an order for CPAP/BiPAP tubing care, and another had orders for CPAP placement at bedtime, humidification, reservoir care, daily mask and cushion cleaning, and weekly tubing care. Staff interviews showed inconsistent understanding of CPAP cleaning and part replacement responsibilities, with some staff stating tubing was cleaned daily, others stating weekly, and others stating they did not know when parts such as tubing, headgear, or mask were to be cleaned or replaced. The infection preventionist stated nurses were to follow manufacturer instructions and orders for CPAP cleaning and part replacement, and the DNS stated the care plans and orders would be revised to include manufacturer recommendations and instructions.
Infection Control Breaks During Wound Care and Enhanced Barrier Precautions
Penalty
Summary
Infection prevention and control practices were not followed during wound care for one resident with pressure ulcers requiring a wound vacuum dressing and enhanced barrier precautions. During an observed wound vacuum dressing change, staff entered the room with PPE and prepared supplies, but one staff member moved the roommate’s personal water pitcher and rolled the overbed table into place without disinfecting it before placing clean dressing supplies on it. A package of gauze was dropped on the floor and placed back on the table, and staff changed gloves multiple times without performing hand hygiene between glove changes. During the same wound care, staff used the same gloved hand to cleanse inside the wound bed, handled wound treatment with the same glove used during cleansing, and moved from soiled tasks to clean dressing application without hand hygiene. One staff member also responded to a walkie talkie in a uniform pocket and then resumed assisting without changing gloves or performing hand hygiene. Staff later acknowledged the breaks in infection control, including not disinfecting the overbed table, not recognizing the need for hand hygiene between glove changes, and not changing gloves after touching an item from a pocket. Enhanced barrier precautions were also not followed for another resident with chronic wounds and orders for EBP every shift. Although the resident’s orders, care plan, Kardex, and TAR all indicated EBP, repeated observations over several days showed no EBP signage on the room door and no PPE bin available. No staff were observed obtaining or using PPE for the resident’s care, and staff stated they had not used EBP during care despite knowing the resident required it. The infection preventionist confirmed that EBP signage and PPE bins should have been present and that staff were expected to follow the precautions.
Failure to Honor Resident Preferences in Daily Schedules and Bathing
Penalty
Summary
The facility failed to honor the preferences and choices of several residents regarding their daily schedules and bathing routines. Resident 7, who has severe cognitive impairment, requested to lay down after breakfast but was left in their wheelchair for almost an hour before being assisted. This delay occurred despite the resident's known routine of either attending an activity or laying back down after breakfast, which requires assistance from two staff members and a mechanical lift. Resident 50, who is cognitively intact and has a stage 4 pressure ulcer, expressed a preference for showers twice a week, as documented in their care plan. However, they were receiving bed baths instead, allegedly due to their wound VAC, despite no physician orders contraindicating showers. Staff were unaware of the resident's documented preference for showers, leading to a failure in honoring the resident's choice. Residents 69, 276, and 31 also experienced issues with their bathing and daily schedules. Resident 69, who is cognitively intact, was made to wait several hours to go to bed despite their preference to do so earlier. They also received fewer showers than preferred. Resident 276, with mild cognitive impairment, preferred two showers a week but often received bed baths instead. Resident 31, who requires total assistance for transfers, preferred morning showers to participate in activities but often had to wait until later in the day due to staff availability. These failures to accommodate resident preferences were discussed with facility management, highlighting a lack of coordination and communication among staff to ensure resident choices are respected.
Deficiencies in Equipment, Flooring, and Call Light Accessibility
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by several deficiencies observed during the survey. The facility did not ensure that transfer equipment, specifically slings, was available and in good condition. Interviews with staff and residents revealed a shortage of appropriate slings, with some staff using shower slings as regular slings due to unavailability. Observations in the laundry room showed slings with faded labels and frayed seams, which were still being used by staff. The Director of Nursing Services acknowledged the issue and stated that staff should use a chart to select the appropriate sling based on the resident's weight, but damaged slings were still found in circulation. The facility also failed to maintain the flooring in a safe condition. Observations noted gouges in the flooring down to the subfloor in the hallways and rooms. The Maintenance Director was aware of the issue and mentioned having some extra flooring for repairs but was uncertain if there was enough to address all the damaged areas. This lack of maintenance posed a risk of injury to residents and staff. Additionally, the facility did not ensure that call lights were functional and within reach of residents. Several instances were observed where call lights were not audible or accessible to residents, including two residents with a history of falls and mobility issues. Maintenance reports indicated multiple call light repairs in the past month, and staff interviews confirmed the ongoing issues with call light functionality. The Director of Nursing Services was unaware of the extent of the problem, which compromised the residents' ability to call for assistance when needed.
Care Plan Deficiencies in Resident Management
Penalty
Summary
The facility failed to review and revise care plans to accurately reflect the conditions and needs of three residents, leading to potential risks for unmet care needs and diminished quality of life. Resident 34, who was receiving hospice services and had severe cognitive impairment, was observed struggling with poor eyesight. Despite the resident's inability to see their food and the need for assistance, the care plan only mentioned the need for large print materials during activities and did not address the resident's visual impairment adequately. Additionally, the fall mat alarm intended to prevent falls was not consistently placed under the resident's feet, despite a history of falls. Resident 50, who had an indwelling catheter and a history of UTIs, did not have peri-care documented in their care plan, which is essential for preventing infections. The resident expressed concerns about the lack of catheter care, and staff interviews revealed that peri-care was not included in the care plan or Kardex. Furthermore, the resident, who had a stage 4 pressure ulcer, was observed lying on their back for extended periods without repositioning, contrary to standard care practices for pressure ulcer management. The resident was also found without a pressure-relieving cushion in their wheelchair, which was necessary to prevent further skin breakdown. Resident 56's care plan inaccurately reflected the use of a hypnotic medication for insomnia, which had been discontinued months prior. This discrepancy highlights the facility's failure to update care plans following changes in the resident's condition or medication regimen. The repeated deficiency from a previous survey indicates ongoing issues with care plan management and revision within the facility.
Staffing Deficiencies Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by interviews with residents and family members, as well as a review of staffing data and resident council minutes. Residents reported long wait times for call light responses, assistance with daily activities, and medication delivery. The facility's past four quarters of payroll-based journal (PBJ) reports indicated consistently low weekend staffing levels, with no improvements over the past year. The facility assessment revealed a high number of residents requiring two-person assistance for daily care, yet the staffing schedules for February 2025 showed numerous unstaffed shifts, particularly on weekends. The resident council minutes documented ongoing concerns about staffing, including delays in call light responses and medication administration. Interviews with residents and family members corroborated these issues, with reports of wait times ranging from 8 to 45 minutes for assistance. Staff interviews indicated that the facility attempted to staff according to census and acuity, but faced challenges due to call-outs and staff turnover. The facility had multiple openings for NACs and LPNs, and relied on agency staff to fill gaps. Despite efforts to address staffing shortages, the facility continued to operate below the allotted nursing service hours, as evidenced by the staff postings for late February 2025.
Incomplete Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for four residents, which included missing hospice provider notes and orders, lab monitoring results, and complete blood sugar monitoring. For Resident 5, who was readmitted on hospice services, there was no documentation of visits by the hospice nurse or provider since readmission. The hospice documentation was kept in a separate electronic record system (EPIC) that was not accessible to the licensed staff, leading to incomplete medical records. Resident 34, admitted with heart failure, stroke, and heart attack, also lacked hospice progress notes in their medical records. The hospice agency communicated changes through verbal updates and faxed orders, but the progress notes were not integrated into the facility's electronic medical records. This lack of documentation was due to limited access to the hospice's electronic record system by the facility staff. Resident 276's records showed missing documentation for vital signs, wound care, and other monitoring tasks on specific dates. Similarly, Resident 1, who required insulin treatment for diabetes, had no documentation of blood sugar checks prior to insulin administration, despite having a monitoring device. The device's results were not uploaded into any software or app, and the care plan was not updated to reflect the use of the glucose monitoring system. These deficiencies in record-keeping placed residents at risk for medical complications and unmet care needs.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure compliance with infection prevention and control guidelines, as observed in several instances involving staff and residents. During medication administration, a Licensed Practical Nurse (LPN) did not perform hand hygiene or wear personal protective equipment (PPE) while administering insulin to a resident with diabetes and bacteremia. The LPN used bare hands to manipulate the resident's clothing and injected the insulin without gloves, subsequently leaving the room without performing hand hygiene. In another instance, the facility did not adhere to transmission-based precautions for a resident who tested positive for Respiratory Syncytial Virus (RSV). Despite the resident being on droplet isolation precautions, staff members were observed entering the resident's room without the required gown and eye protection. Additionally, staff failed to replace their surgical masks after exiting the isolation room, contrary to the facility's expectations and training. Furthermore, during catheter care for a resident with a Foley catheter and colostomy bag, staff members did not perform hand hygiene between glove changes. Staff were observed donning new gloves without using alcohol-based hand rub (ABHR) after removing soiled gloves, and continued to provide care and handle equipment without proper hand hygiene. The facility's infection preventionist and Director of Nursing Services were unaware of these lapses, which were not in line with the facility's policies and training.
Deficiency in Providing Assistance for ADLs
Penalty
Summary
The facility failed to provide necessary assistance for oral care and bathing for three residents who were dependent on staff for these activities of daily living. Resident 69, who was cognitively intact and required extensive assistance for bathing, reported receiving only two showers and one bed bath since admission, despite expressing a preference for two showers a week. Documentation confirmed that Resident 69 had only three bathing tasks recorded. Similarly, Resident 276, who had mild cognitive impairment and was totally dependent on staff for bathing, reported receiving only one shower and one bed bath since admission, with records confirming a lack of regular bathing. Resident 20, who had mild cognitive impairment and required assistance with oral care, reported sleeping with dentures in their mouth and expressed a desire for them to be removed and cleaned nightly. Despite recommendations from dental notes for staff to assist with brushing and denture removal, interviews with staff revealed that oral care was not provided. The Director of Nursing Services was unaware of any issues with oral care or bathing not being completed, and there was no shower policy in place, only a standard of care. This deficiency was a repeat issue from a previous statement of deficiencies.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted in a location readily accessible to residents and visitors, and that it included the required information on two of the six days during the recertification survey. On February 23, 2025, at 7:45 AM, the posted nurse staffing information was observed to be dated February 21, 2025, with no updated forms for February 22 or 23, 2025. The posted information for February 21, 2025, was incomplete, showing only the total actual hours worked for the day shift, while the evening and night shifts were left blank. Staff H, the Staffing Coordinator, was responsible for posting the daily staffing information and relied on another staff member to complete it on weekends. However, Staff H was unaware of why the postings for February 22 and 23, 2025, were not completed. Staff B, the Director of Nursing Services, confirmed that Staff H was responsible for the postings and was unaware of the missing information for those dates.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to ensure a system was in place to accurately reconcile controlled medications, specifically narcotics, in one of the five medication carts reviewed. During an observation and interview, a Registered Nurse, Staff V, was counting narcotic medications and found discrepancies in the narcotic book for the [NAME] Cart. The book indicated that there should be one tablet left on two separate pages, but there were no narcotic medications present in the cart. Staff V acknowledged the discrepancy and stated that the count was incorrect, indicating that the pages should show zero. Staff V planned to inform the Resident Care Manager (RCM) to initiate an investigation. Further investigation by Staff L, a Licensed Practical Nurse and RCM, revealed that the licensed nurses who administered the last doses of the medications failed to sign them out in the narcotic book, although they had signed their initials in the Medication Administration Record (MAR) indicating the medications were given. Staff L stated that the process for counting narcotics required licensed nurses to review every page of the narcotic book for accuracy and report any discrepancies to the RCM. The Director of Nursing Services, Staff B, confirmed the expectation that licensed nurses should check every page of the narcotic book and report discrepancies to the RCM or DNS. The facility was able to reconcile the narcotic book for the [NAME] Cart.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper management and storage of medications and biologicals, leading to several deficiencies. During observations, two medication carts were found unlocked and unattended, with over-the-counter medications and bubble-packed medicine cards accessible. Additionally, controlled medications, specifically Lorazepam, were stored in a refrigerator that was not affixed to the floor, and the container holding the medication was not secured. This lack of secure storage for controlled substances was a significant oversight. Furthermore, the facility did not adequately monitor the expiration dates of medications and vaccines. Expired medications, including Loratadine and Simethicone, were found in medication carts, and expired Afluria flu vaccines were discovered in a refrigerator. Interviews with staff revealed that the night shift nurse was responsible for checking and discarding expired medications, but this process was not effectively implemented, leading to expired items remaining in use. The Director of Nursing Services was unaware of the requirement for controlled medications to be stored in a firmly affixed container, indicating a gap in knowledge and adherence to regulations.
Delayed Laboratory Results Impact Resident Care
Penalty
Summary
The facility failed to provide timely laboratory results for two residents, which had the potential for negative complications due to delays in obtaining and following up on laboratory results. Resident 277, who was admitted with multiple diagnoses including diabetes and kidney disease, reported symptoms of a urinary tract infection (UTI) but experienced delays in testing and receiving results. Despite the resident's complaints and a physician's order for a urinalysis, the sample was not processed due to logistical issues with the contracted lab, which resulted in a delay in diagnosis and treatment. Resident 279, admitted with septic shock and nutritional deficiency, also experienced delays in laboratory testing. A stool sample was collected to test for Norovirus and other infections, but the sample was not processed due to being overfilled. The contracted lab's slow turnaround time and logistical challenges in sample collection and processing contributed to the delay in obtaining results, which could have impacted the resident's care and treatment. The facility's Director of Nursing and other staff members expressed concerns about the reliability and timeliness of the contracted lab services. They reported ongoing issues with sample processing and communication from the lab, which often resulted in the need for re-collection of samples. The facility was actively seeking local lab services to improve turnaround times and ensure timely and accurate diagnostic testing for residents.
Failure to Obtain Order and Clean CPAP Machine
Penalty
Summary
The facility failed to ensure a physician order was obtained and routine cleaning was provided for a CPAP machine for a resident. The resident, who was admitted with chronic obstructive pulmonary disease, obstructive sleep apnea, and chronic respiratory failure, had their CPAP machine brought into the facility from home. However, the Admission Minimum Data Set assessment did not code the CPAP machine, and the resident's care plan did not include the use of the CPAP machine. During an observation and interview, the resident stated that the staff had not cleaned their CPAP machine. The Order Summary Report showed no order for CPAP machine usage or cleaning. Staff members, including a Licensed Practical Nurse and the Director of Nursing Services, were unaware of the CPAP machine's presence and confirmed the absence of an order for its use or cleaning.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident who was dependent on staff for care. The resident, who had diagnoses including paranoid schizophrenia, urine retention, overactive bladder, and muscle weakness, was unable to communicate effectively and required extensive assistance with meals, bed mobility, transfers, toileting, and hygiene. Despite these needs, the facility did not consistently provide the necessary care, as evidenced by observations and interviews with staff and caregiver agency personnel. On multiple occasions, the resident was left without proper meal assistance, as the caregiver agency staff responsible for feeding them arrived after breakfast was served, leaving the meal untouched for extended periods. Additionally, the facility staff did not adequately monitor or assist the resident with incontinence care, as the resident was found soaked in urine on at least one occasion. Interviews with staff revealed inconsistencies in the care provided, with some staff members acknowledging the resident's refusal of care and others failing to perform essential tasks such as brushing the resident's teeth. The facility's care plan for the resident was not updated to reflect the involvement of the caregiver agency, leading to a lack of coordination and oversight in the resident's care. The Director of Nursing Services admitted to not reviewing the care plan until recently, indicating a lapse in ensuring that the resident's needs were met. This deficiency in care placed the resident at risk for a diminished quality of life, as their basic needs for hygiene, nutrition, and comfort were not consistently addressed.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide assistance with activities of daily living, including personal hygiene and bathing, for two residents who were dependent on staff for these needs. Resident 1, diagnosed with cerebral palsy and joint pain, required substantial assistance with personal hygiene and bathing. However, documentation showed that Resident 1 received only two baths in 17 days. Observations and interviews revealed that Resident 1 often had food remnants on their shirt, indicating a lack of assistance with cleaning up after meals, which bothered the resident. Resident 3, diagnosed with stroke, paralysis, and major depressive disorder, also required substantial assistance with personal hygiene and bathing. Documentation showed that Resident 3 received only one bed bath in two weeks. Observations and interviews revealed that Resident 3 had food remnants on their body and in their hair, and expressed a desire for more frequent showers. Staff interviews confirmed that residents should be offered baths regularly and that refusals should be documented and followed up with education on personal hygiene. This deficiency was a repeat citation from a previous survey.
Failure to Manage Constipation in Resident
Penalty
Summary
The facility failed to ensure the needed care and services for a resident with constipation, muscle weakness, and pain. The resident had physician orders for Polyethylene Glycol (MiraLAX) daily, Milk of Magnesia (MOM) as needed if no bowel movement (BM) for three days, and Bisacodyl suppository if MOM had no results. Despite these orders, the resident experienced multiple periods without a BM, including five days from 04/15/2024 to 04/19/2024, four days from 04/27/2024 to 04/30/2024, and six days from 05/01/2024 to 05/06/2024. The resident refused the Polyethylene Glycol on several occasions, and there was no documentation that the provider was notified of these refusals or the lack of BMs. MOM and Bisacodyl suppository were not administered as per the bowel protocol during these periods. Interviews with staff revealed that the nurses were responsible for managing residents' BMs and following the bowel regimen. However, there was a lack of consistent documentation and communication regarding the resident's medication refusals and bowel movements. The nursing progress note and hospice visit summary indicated that the resident had gone eight days without a BM and had refused the bowel medications, but there was no indication that the provider was notified. This deficiency was a repeat citation from previous surveys conducted on 03/26/2024 and 04/23/2023.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 143 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bellingham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avalon Healthcare Bellingham | 1.5 mi | ★★★★★ | 15 | 0 |
| North Cascades Health And Rehabilitation | 2.2 mi | ★★★★★ | 45 | 1 |
| Shuksan Rehabilitation And Health Care | 2.5 mi | ★★★★★ | 5 | 0 |
| Mt Baker Care Center | 4.7 mi | ★★★★★ | 2 | 0 |
| Highland Health And Rehabilitation Of Cascadia | 5.2 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Alderwood Park Health And Rehab Of Cascadia.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.