Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Avalon Healthcare Bellingham during CMS and state inspections, most recent first.
A facility failed to provide and document restorative nursing programs for three residents with stroke-related weakness, contractures, and Parkinson’s disease. One resident was repeatedly observed without ordered splints or orthotics despite a care plan for ROM and mobility support, another had therapy discharge recommendations for active and passive ROM and standing-frame activities but no documentation the program was completed, and a third had a restorative care plan with no progress note evidence of the program. Staff stated restorative duties were left to floor aides, OT recommendations were not further communicated, and one resident was not actually on a restorative program.
A resident with pneumonia and newly diagnosed metastatic cancer was started on an antidepressant for depression, but the care plan was not updated for weeks and required psychotropic monitoring was not documented. The record showed no target behaviors, behavior monitors, or adverse side effect monitors, and the DON confirmed the process for reviewing the new order and ensuring consent and monitoring was missed.
Baseline Care Plan Missing Key Admission Information: The facility failed to include essential admission information in the baseline care plan for two residents. One resident with quadriplegia had edema and an order for compression gloves, but the care plan did not address edema management. Another resident was a current smoker with smoking-related orders and PASSR history, but the care plan did not include smoking risk, history, goals, or interventions.
Failure to obtain ordered monthly weights for a resident with obesity and HTN. The resident had a physician order for monthly weights and a care plan goal to avoid significant wt loss, but the EHR had no documented weights for several months. The RD, LPN, RN/unit manager, and DON all confirmed the missing weights, and no documentation of refusals was found.
Failure to implement pressure ulcer prevention interventions affected a resident with stroke-related hemiparesis and diabetes who was at risk for skin breakdown. The resident developed a stage 2 pressure injury on the left outer ankle, but charting showed no documentation that ordered offloading measures such as pillows or foam boots were being used or that the resident refused them. Observations showed the resident in bed with feet flat on the mattress while the foam boots were left on the wheelchair.
A resident who was a current smoker had incomplete smoking screening and care planning, despite a history of smoking more than 10 cigarettes per day, mild short-term memory loss, and later documentation that the resident smelled of cigarettes, admitted to smoking outside, and possessed smoking materials. The resident’s smoking-related interventions were not reflected in the care plan, and staff noted the resident had been identified as smoking after family brought cigarettes and a lighter into the facility.
Failure to maintain CPAP equipment and cleaning for two residents. One cognitively intact resident reported the CPAP had never been cleaned during the year of stay, with no new tubing, headgear, or nasal pillows since admission and a dirty filter. Another resident with moderate cognitive impairment had a dusty CPAP, reported needing new tubing and a face mask, and said staff had not replaced the equipment. Staff were unsure of replacement schedules, vendor information, and manufacturer guidelines.
An expired Narcan nasal spray was found in medication cart #2 on B wing during a cart review. An LPN confirmed the expiration date, and the DON stated the pharmacy had recently completed cart audits and staff nurses were asked to audit the carts, but they were unsure how the expired medication was missed.
Immunization records and consent documentation were incomplete for 3 residents. One resident with respiratory failure, anoxic brain injury, and moderate cognitive impairment had influenza and pneumococcal vaccine refusals documented, but the informed consent section was left blank and no verbal consent was recorded. Two other residents had incomplete documentation of prior flu and pneumococcal vaccine history, and one consent form did not address pneumococcal status.
The facility failed to ensure COVID-19 vaccine education, offer, and documentation were completed for two residents. One resident with respiratory failure, anoxic brain damage, and moderate cognitive impairment had a COVID-19 refusal recorded, but the consent form lacked completed informed consent elements and verbal consent was marked no. Another resident's admission record listed COVID-19 refusal as already received, but there was no documentation of prior vaccine dates or status, and the DON noted the hospital records did not show COVID-19 vaccination information.
A resident with impaired mobility and sensation developed an unstageable, later Stage 4, sacral pressure ulcer that became infected and required hospitalization after staff failed to consistently reposition, monitor, and implement pressure offloading interventions as care planned. Documentation and staff interviews revealed inconsistencies in care delivery, lack of timely updates to the care plan, and insufficient monitoring, despite the resident being identified as at risk for pressure ulcers.
A resident with multiple diagnoses was transferred to the hospital without the facility notifying their Guardian of abnormal lab values or the transfer. The Guardian was informed by hospital staff instead. An LPN attempted to contact the Guardian but did not leave a message or use the on-call option. The DON confirmed the expectation for communication of such changes.
The facility's activity program was directed by an unqualified professional, leading to low resident engagement and dissatisfaction. The Recreation Director lacked necessary certification, and the administrator acknowledged the issue without an active plan for correction. Residents reported boredom and insufficient engagement, with observations showing minimal participation in scheduled activities.
The facility failed to provide care and treatment according to professional standards for several residents, leading to unmet care needs and potential medical complications. A resident with heart failure did not receive required weights and was observed without a necessary bandage. Another resident with kidney disease missed lab tests due to a change in lab providers. A resident on Depakote experienced issues with medication administration and lab draws. A resident with pressure ulcers did not receive consistent nutritional support, and a resident with chronic conditions refused TED hose without alternatives offered.
A facility failed to ensure proper delegation of resident rights for decision-making for a resident with severe cognitive impairment. The resident's care plan incorrectly listed a deceased family friend as the POA, while the daughter was the next of kin. Despite the resident's inability to make informed decisions, their signature appeared on legal documents. Staff interviews revealed confusion about the process for determining decision-making capacity and obtaining informed consent.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in addressing specific needs such as congestive heart failure, discharge planning, and therapy goals. Residents expressed stress and confusion due to the lack of communication and documentation regarding their care and discharge plans.
A facility failed to assist a resident with ADLs, including grooming and clothing changes, despite the resident's need for assistance due to cognitive and physical impairments. Observations showed the resident wore the same soiled clothing and had unshaven facial hair over several days. Staff interviews confirmed the resident did not refuse care, indicating a lack of adherence to the care plan.
A resident with a history of stroke and post-polio syndrome, who was cognitively intact and dependent on staff for toileting, experienced extended waiting times for assistance despite a specific toileting schedule. Observations showed repeated delays and inadequate response to call lights, with staff turning off the call light without providing care. Interviews revealed a lack of communication and coordination among staff, leading to the resident's unmet toileting needs.
Two residents experienced avoidable accidents due to the facility's failure to follow individualized care plans and provide adequate supervision. One resident, with a history of stroke, fell from bed and sustained a head injury when a CNA assisted them alone, contrary to the care plan. Another resident, with hemiplegia, left the facility unsupervised and was found by police at a nearby hospital. Investigations revealed staff did not adhere to care plans, contributing to these incidents.
A facility failed to maintain a resident's confidentiality when an LPN provided a care plan to an unauthorized visitor. The resident's POA confirmed that the visitor was not authorized to receive any private information. This breach violated the facility's policy on privacy and confidentiality, risking the resident's right to privacy and preference.
The facility failed to thoroughly investigate incidents involving two residents. One resident, with a history of stroke, fell due to a CNA not following the care plan requiring two-person assistance. Another resident, with hemiplegia, eloped from the facility, and the investigation did not assess the care plan for supervision needs. The DNS confirmed the expectation for staff to follow care plans, but investigations were insufficient.
Restorative Nursing Programs Not Provided or Documented
Penalty
Summary
The facility failed to provide necessary care and services related to restorative nursing programs for three residents reviewed for positioning, mobility, and range of motion. The deficiency was identified during observation, interview, and record review and involved residents with stroke-related weakness, contractures, Parkinson’s disease, and impaired ROM. The report states the failed practice placed residents at risk for decline in function, contractures, pain, and increased dependency on caregivers. One resident admitted with hemiplegia and hemiparesis after a cerebral infarction had a care plan for a restorative nursing program to maintain ROM and functional mobility, including ROM to the left hand, passive ROM to the hips, knees, ankles, and bilateral upper extremities, and use of a palm protector, resting hand splint, and elbow extension splint. The resident’s record showed the last restorative evaluation was completed months earlier, and OT documentation noted impaired ROM in the left wrist and fingers with recommendations for specialized orthotic assessment. During multiple observations over several days, the resident was repeatedly seen without the ordered devices in place, and the resident stated the splint had been missing. Staff interviews showed the restorative program was being left to floor aides, the restorative aide had been pulled to the floor, OT recommendations were only documented and not communicated further, and the administrator and DON stated the facility did not have a restorative position or program. A second resident admitted after a stroke with right-sided hemiparesis had therapy discharge recommendations for active ROM, passive ROM to the right upper extremity, and supported standing frame activities several times per week. The resident and spouse stated therapy had ended and that the resident was not getting exercises other than a dining room group program. The record showed the restorative programs were included on the care plan and in nursing assistant task documentation, but there was no documentation that the programs were actually completed. Staff confirmed the documentation was absent and stated the dining room exercise group did not provide passive ROM or one-on-one assistance. A third resident with Parkinson’s disease had a care plan for a restorative program to maintain function, with exercises and stretches three to six times per week as tolerated. Review of progress notes showed no information regarding the restorative program, and a unit manager stated the resident was not on a restorative program. Across the three residents, the report documents that restorative nursing services were not consistently provided or documented as planned.
Unnecessary Psychotropic Medication Monitoring Not Implemented
Penalty
Summary
The facility failed to ensure that one resident receiving a newly ordered antidepressant was free from unnecessary psychotropic medication use. Resident 5 was admitted with diagnoses including pneumonia and newly diagnosed metastatic cancer, and on 10/21/2025 the medical record documented an order for a new antidepressant related to a new diagnosis of depression. The resident’s care plan was not updated to include a depression problem, goals, or interventions until 11/20/2025. Although the care plan instructed staff to identify and monitor target behaviors of depression every shift and to monitor and document potential adverse effects of the antidepressant every shift, review of the record on 12/04/2025 showed no documentation that these interventions had been implemented. There were no identified target behaviors for the resident’s depression, no behavior monitors, and no adverse side effect monitors found in the record. Staff C stated that residents with psychotropic medications should have monitors set up when orders are received, and Staff B confirmed that the process for reviewing new orders and ensuring consent, target behaviors, and monitors were in place was missed for Resident 5.
Baseline Care Plan Missing Key Admission Information
Penalty
Summary
The facility failed to ensure the baseline care plan included the minimum health information necessary to properly care for residents within 48 hours of admission for 2 of 5 residents reviewed. For Resident 77, who was admitted with diagnoses including quadriplegia, an observation on 12/01/2025 found swollen left and right hands, and the resident stated they had compression gloves for swelling but staff had removed them earlier. The admission evaluation completed on 11/24/2025 documented no edema, and the treatment administration record for November 2025 included an order for compression gloves to both hands for edema management, but the baseline care plan dated 11/25/2025 did not document the need for compression gloves to manage edema. For Resident 5, who was admitted as a current smoker, the admission smoking screen dated 07/25/2025 documented smoking greater than 10 cigarettes per day in the morning, afternoon, and evening, and the level 1 PASSR listed a substance abuse history and smoking. The physician's orders dated 07/25/2025 included a smoking cessation patch and nicotine gum as needed, but the resident's baseline care plan did not include the risk to smoke, smoking history, goals, or interventions. Staff stated the assessments should auto-populate to the care plans and did not know why the smoking information was not included, and another staff member stated the care plans should be reviewed to ensure they were complete.
Failure to Obtain Ordered Monthly Weights
Penalty
Summary
The facility failed to follow a physician's order to obtain monthly weights for Resident 11, who was admitted with diagnoses including obesity and high blood pressure. The resident's medication administration record included an order for a monthly weight, and the care plan dated 10/24/2024 stated the goal was for the resident not to have significant weight loss of more than five percent in 30 days or ten percent in 180 days. However, the resident's electronic health record contained no documentation of weights for September, October, or November 2025. Staff L, the RD, stated the resident was triggered for review because there had been no documented weight since August 2025. Staff K, an LPN, stated they had just obtained the resident's weight, and Staff R stated weights were typically done around the first of the month and reported by nursing assistants. Staff C, the RN/unit manager, stated the resident was missing weights for September, October, and November 2025 and that no documentation could be found showing the resident refused weights during those months. Staff B, the DON, stated they were made aware of the missing weights.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
Failure to ensure pressure ulcer prevention interventions were implemented affected Resident 67, who was admitted following a stroke with residual right-sided hemiparesis and also had diabetes. The resident’s admission MDS indicated no skin impairments but identified the resident as at risk for pressure ulcers/injuries. The care plan dated 03/18/2025 directed staff to use a pressure relieving/reducing mattress and pillows to protect the skin while in bed. Resident 67 developed a stage 2 pressure injury on the left outer ankle measuring 2 cm x 1 cm, identified on 10/23/2025. The care plan was updated the next day to include elevating both lower extremities with pillows or using foam boots for additional pressure relief and documenting acceptance or refusals. However, the record reviewed on 12/04/2025 contained no documentation showing the interventions were implemented or that the resident accepted or refused them. Observations on 12/01/2025, 12/02/2025, and 12/03/2025 showed the resident in bed with feet and ankles flat on the mattress, while the green foam boots were observed sitting on the wheelchair seat and not in use. The resident stated they had a sore on the ankle and did not know how it occurred or why the foam boots were not on. Staff stated the resident would wear the boots if they were put on and needed extensive assistance for mobility and positioning. During wound care, the RN observed a small open area over the bony aspect of the left outer ankle and stated the dressing was protective and that the resident should have heels and feet offloaded in bed.
Failure to Supervise Resident Smoking and Update Care Plan
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for one resident who was reviewed for smoking. The resident was admitted as a current smoker, was alert and oriented with mild short-term memory loss, and had a level 1 PASSR noting a substance abuse history and smoking. The admission smoking screen documented that the resident smoked more than 10 cigarettes per day, but the remainder of that screen was marked N/A because the facility was non-smoking. A second smoking screen was blank, and the resident’s care plan did not address the resident’s current or former smoking except for a reference that it contributed to respiratory disease. The record showed the resident had orders for a smoking cessation patch and nicotine gum as needed, which were later discontinued. Progress notes documented that the resident smelled of cigarettes, admitted to going outside and smoking, and possessed smoking materials; the resident also stated awareness that the facility property was non-smoking and declined resuming smoking cessation. A later smoking screen identified smoking-related goals and interventions, including instruction on smoking risks, facility policy, and observation for cigarette burns, but the care plan was not updated to include those interventions. During interview, the resident stated they still smoked occasionally, denied possessing smoking materials, and said family provided cigarettes and a lighter when taking them out. Staff stated the smoking information should have been reflected in the care plan and that the resident had been identified as having smoked after family brought cigarettes and a lighter into the facility.
Failure to Maintain CPAP Equipment and Cleaning for Two Residents
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents who used CPAP therapy for obstructive sleep apnea. Resident 44, who was cognitively intact, had physician orders to use CPAP when sleeping, wash the tubing with warm water and baby shampoo, rinse and dry it, verify the CPAP was off in the morning, and empty, dry, and refill the humidifier chamber with distilled water at bedtime. The resident stated the CPAP had never been cleaned during the year they had been in the facility, had not received new tubing, headgear, or nasal pillows since admission, and the back filter was fluffy and grey. The resident also stated they were unaware the filter existed or that it needed to be changed every 2 weeks. Resident 49, who had moderate cognitive impairment, was observed with a black Phillips CPAP at the foot of the bed with visible dust on it and stated they slept with the machine. The resident reported taking out the filter, wanting new tubing and a new face mask, replacing the hose six months earlier because it broke, and not having a new face mask since admission. The resident also stated they had repeatedly asked staff for supplies. Staff interviews showed the LPN usually cleaned the CPAP and filled the water at night but was unaware of the replacement schedule, and the RN/Resident Care Manager stated they knew the residents used CPAPs and that nurses filled the reservoirs with distilled water, but were unsure of the vendor, whether the headgear, mask, tubing, and reservoir had been replaced, and did not have the manufacturer's guidelines available at the time.
Expired Narcan Found in Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles when an expired Narcan nasal spray was found in medication cart #2 on B wing during observation. During the cart review, the Narcan was observed with an expiration date of 08/2024, and an LPN confirmed the expiration date during interview. The DNS stated that the pharmacy had recently completed medication cart audits and that staff nurses were asked to audit the carts, but they were unsure how the expired medication was missed.
Immunization records and consent documentation incomplete
Penalty
Summary
The facility failed to ensure influenza and pneumococcal immunizations were offered, kept up to date, and that the risks and benefits of the immunizations were provided for 3 of 6 residents reviewed for immunization and infection control: Resident 67, Resident 54, and Resident 80. The facility policy titled, Infection Prevention and Control, Influenza and Pneumococcal Immunizations, dated 02/2025, stated the facility would provide influenza and pneumococcal immunizations, residents and/or representatives would receive information related to the risks and benefits, and the medical record would reflect education and administration or refusal of the immunization. Resident 80 was admitted with respiratory failure and anoxic brain damage, and the MDS dated 11/28/2025 documented moderate cognitive impairment. The record showed two individuals listed as durable power of attorney, but the immunization consent evaluation dated 11/21/2025 had the resident declining influenza and pneumococcal immunizations with the acknowledgment and informed consent section left blank, no verbal consent documented, and the resident's name electronically printed in the signature box. Resident 54's admission immunization consent documented refusal of influenza vaccination with the reason stated as already received, but there was no documentation of prior immunization history dates. Resident 67's immunization consent dated 09/18/2025 showed consent for seasonal influenza vaccination, but it did not address pneumococcal vaccine status, and the immunization tab on admission stated only refused with no corresponding historical data for pneumococcal vaccination. The DON stated the facility could use the state immunization portal, hospital documentation, or provider records to determine immunization history and whether residents were up to date, and after reviewing Resident 54's records stated hospital documentation showed the last influenza vaccine was in 2022; the DON also stated further review would be needed to determine whether Resident 67 was up to date on pneumococcal vaccination.
COVID-19 Immunization Education and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure COVID-19 immunizations were offered, kept up to date, and that the risks and benefits of the immunizations were provided to 2 of 6 residents reviewed for immunization and infection control, identified as Resident 54 and Resident 80. The facility policy titled, Infection Prevention and Control, COVID-19 Immunization, dated 12/07/2023, stated residents would be offered COVID-19 vaccinations and educated on the benefits, risks, and potential side effects before consent was requested, with documentation to include the education, offer of vaccine, date, who received the education, the authorized representative, and whether the resident accepted or refused. Resident 80 was admitted with diagnoses including respiratory failure and anoxic brain damage, and the MDS dated 11/28/2025 documented moderate cognitive impairment. The medical record showed two individuals listed as durable power of attorney, but the immunization record documented refusal of COVID-19 vaccination and the electronic consent evaluation dated 11/21/2025 showed the resident declined the immunizations without completed acknowledgement and informed consent sections; the verbal consent question was marked no, and the resident's name was electronically printed in the signature box. Resident 54's admission immunization consent documented refusal of the COVID-19 vaccination with the reason stated as already received, but there was no documentation of prior immunization history dates. The DON stated the facility could use the state immunization portal, hospital documentation, or provider records to determine immunization history and whether residents were up to date, and reviewed Resident 54's records, noting the hospital documentation did not show COVID-19 vaccination status.
Failure to Prevent and Manage Pressure Ulcer Resulting in Harm
Penalty
Summary
The facility failed to consistently reposition, assess, and monitor skin integrity in a timely manner, and did not implement pressure offloading interventions to prevent the development of avoidable pressure ulcers for a resident identified as being at risk. The resident, who had a history of right hip fracture, spina bifida with impaired sensation, and required substantial assistance with mobility, was admitted without any pressure ulcers but was assessed as being at risk for their development. The care plan and Kardex indicated the need for staff assistance with turning and repositioning, as well as the use of pressure-relieving devices, but documentation and staff interviews revealed inconsistencies in the implementation and communication of these interventions. Despite being care planned for frequent repositioning and pressure relief, the resident developed an unstageable pressure ulcer on the sacrum, which was later diagnosed as a Stage 4 ulcer and became infected, requiring hospitalization. The resident and their family reported that after therapy services ended, staff did not assist with repositioning or provide reminders, and the resident, due to sensory loss, was unaware of the developing ulcer. Staff interviews indicated confusion regarding the level of assistance required for bed mobility and repositioning, and there was a lack of documentation regarding refusals of care or updates to the care plan in response to changes in the resident's condition or cooperation. Facility policy required individualized prevention and treatment plans, daily and weekly monitoring of pressure ulcers, and consistent implementation of interventions for residents at risk. However, the investigation found that the care plan was not consistently updated or followed, and there was insufficient documentation of care provided or resident refusals. The lack of timely and consistent interventions, monitoring, and communication among staff contributed to the development and worsening of the resident's pressure ulcer, resulting in significant harm.
Failure to Notify Resident's Guardian of Health Changes
Penalty
Summary
The facility failed to ensure proper notification of changes in health status for a resident, identified as Resident 1, who was admitted with diagnoses including schizoaffective disorder, encephalopathy, major depressive disorder, and anxiety. The medical record indicated that a Guardian was listed as the responsible party and emergency contact for Resident 1. However, the facility did not document any notifications made to the Guardian regarding abnormal lab values or the resident's transfer to the hospital on the specified date. Interviews revealed that the Guardian, referred to as CC1, was not informed by the facility about the resident's health changes or hospital transfer. Instead, CC1 learned of these events from hospital staff after the transfer. Staff C, an LPN and Unit Manager, admitted to attempting to contact the Guardian but did not leave a message or use the on-call option for emergencies. The Director of Nursing Services, Staff B, confirmed that it was expected for any changes in a resident's condition to be communicated to their representative, which did not occur in this instance.
Unqualified Activities Director and Low Resident Engagement
Penalty
Summary
The facility failed to ensure that its activity program was directed by a qualified activities professional, as required by regulations. The Recreation Director, Staff S, did not possess the necessary certification or qualifications for the role, having only an associate's degree in arts and science and prior experience in a memory care facility. This lack of qualification was acknowledged by the facility's administrator, Staff A, who admitted there was no active plan to rectify the situation. The deficiency was identified through interviews and observations that revealed low participation in scheduled activities and a lack of engagement with residents. Residents expressed dissatisfaction with the activities offered, citing boredom and a lack of personalized engagement. Observations showed minimal resident participation in scheduled activities, such as flower arranging and exercise groups, with only a small fraction of the 64 residents attending. Interviews with residents and staff highlighted issues such as insufficient one-to-one visits and a lack of interest in the activities provided. Staff S admitted to not addressing the low attendance and lack of interest in the Quality Assurance and Improvement Committee (QAPI) meeting, further contributing to the deficiency.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards for several residents, leading to unmet care needs and potential medical complications. Resident 6, diagnosed with congestive heart failure and cerebral infarction, did not receive the required weights on specified dates, and was observed without a necessary bandage on their nose despite documentation indicating otherwise. Staff interviews revealed a lack of adherence to procedures for obtaining weights and completing treatments as ordered. Resident 24, with a diagnosis of kidney disease, did not have required lab tests conducted as per physician orders. The facility's change in lab providers contributed to missed lab draws, and staff were unaware of these omissions until the survey. Similarly, Resident 29, who was prescribed Depakote for bipolar disorder, experienced issues with medication administration and lab draws, with staff failing to follow up on the resident's requests and the physician's orders for lab tests. Resident 53, suffering from a traumatic brain injury and pressure ulcers, did not receive consistent nutritional support as recommended by the dietician, and there was a lack of documentation for weekly wound specialist visits. The transition to a new company resulted in missing wound consultant notes, which were crucial for ongoing treatment and care planning. Additionally, Resident 23, with multiple chronic conditions, refused to wear TED hose due to discomfort, but no alternative solutions were offered, and staff failed to notify the provider of the resident's refusals.
Failure to Ensure Proper Delegation of Resident Rights for Decision-Making
Penalty
Summary
The facility failed to ensure proper delegation of resident rights for decision-making and informed consent for a resident with a traumatic brain injury. The resident, who was admitted with severe cognitive impairment, had no documented Advance Directives or decision-making hierarchy in their clinical record. The resident's care plan incorrectly listed a deceased family friend as the Power of Attorney (POA), while the resident's daughter was identified as the next of kin. Despite the resident's inability to make informed decisions, their signature appeared on several legal documents, including admission and arbitration agreements. Interviews with facility staff revealed a lack of clarity and understanding regarding the process for determining decision-making capacity and obtaining informed consent. Staff members were unsure of the procedures to follow when a resident lacked clear Advance Directives and decision-making capacity. The facility eventually provided a letter from the medical director stating the resident's incapacity to make healthcare decisions, but this was after the deficiency was identified.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, leading to deficiencies in addressing their specific needs. Resident 6, who was admitted with chronic congestive heart failure, was observed to have persistent edema in both feet over several days. Despite these observations, the resident's care plan lacked specific interventions to address the congestive heart failure and associated edema, only including a general intervention to monitor and report signs of heart failure. For Resident 51, who was admitted with heart and liver problems and a history of alcohol use disorder, the care plan did not include a focus area for discharge planning, despite the resident's goal to return to the community. The resident expressed confusion and stress about the lack of a discharge plan, as they felt ready to go home and were no longer receiving therapy. Similarly, Resident 54, who was working with therapy to improve strength, also lacked a care plan focus on therapy goals or discharge planning, leaving the resident uncertain about their discharge timeline and future living arrangements. Resident 215, admitted with a left arm fracture, high blood pressure, and muscle weakness, also did not have a discharge plan included in their care plan, despite having an active discharge goal. The resident expressed stress over the lack of communication regarding their discharge plan. Interviews with staff revealed that the facility's process for updating care plans was lacking, with discharge planning not being adequately documented or communicated to residents, contributing to the deficiencies identified in the survey.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to assist a dependent resident, identified as Resident 6, with routine activities of daily living (ADLs), which included grooming and clothing changes. Resident 6, who was admitted with diagnoses such as stroke with hemiplegia, congestive heart failure, dementia, and depression, required supervision and assistance due to cognitive impairments and physical limitations. Despite the care plan directing staff to assist with clothing choices and grooming, including shaving twice a week, observations over several days showed that Resident 6 wore the same soiled clothing and had unshaven facial hair, indicating a lack of adherence to the care plan. Interviews with staff members revealed that Resident 6 did not refuse care, contradicting any assumption that the resident's condition was due to refusal. Staff members, including a Social Services staff, Nursing Assistant Certified (NAC), and the Director of Nursing, acknowledged the resident's need for assistance with ADLs and confirmed that the resident did not refuse care. The Director of Nursing was aware of the issue but noted that the care plan did not reflect any refusals of care, highlighting a gap in the facility's documentation and execution of the resident's care plan.
Failure to Provide Timely Toileting Assistance for a Resident
Penalty
Summary
The facility failed to provide necessary care and services to maintain continence for Resident 49, who was reviewed for incontinence. Resident 49, who was cognitively intact and dependent on staff for toileting needs, was admitted with diagnoses including stroke and post-polio syndrome. The resident's care plan required two-person maximum assistance using a Hoyer lift for toilet use and included a specific toileting schedule. However, the facility did not adhere to this schedule, leading to extended waiting times for toileting assistance. Observations and interviews revealed that Resident 49 often waited for an hour or more before receiving assistance, despite being continent and able to identify when they needed to urinate or have a bowel movement. The resident's representative, CC1, reported multiple complaints about the issue, noting that staff would turn off the call light, preventing the system from registering the waiting time. During one observation, the resident's call light was repeatedly turned on and off without providing the necessary care, and staff were delayed in assisting due to being occupied with other tasks. Staff interviews indicated a lack of communication and coordination in addressing Resident 49's toileting needs. Staff C, an LPN, acknowledged that the times on the Kardex were directed by CC1 but had not discussed specific time frames with them. Additionally, Staff C expected call lights to be answered within 10 minutes but had not conducted a bladder assessment for Resident 49. This lack of timely and coordinated care placed Resident 49 at risk for further decline in bowel and bladder function, as well as potential skin issues and emotional distress.
Failure to Follow Care Plans and Provide Supervision Leads to Resident Accidents
Penalty
Summary
The facility failed to provide adequate supervision and follow individualized care plans, resulting in avoidable accidents for two residents. Resident 1, who had a history of stroke and left-sided hemiparesis, required extensive assistance for bed mobility and incontinence care as per their care plan. However, a CNA assisted Resident 1 alone, contrary to the care plan's requirement for two-person assistance. During this unsupervised care, Resident 1 fell from the bed, sustaining a head injury that required hospitalization. Resident 2, diagnosed with hemiplegia and muscle weakness, required supervision and assistance for transfers and ambulation according to their care plan. Despite this, Resident 2 was able to leave the facility unsupervised and was found by police at a nearby hospital. The investigation revealed that staff did not witness Resident 2 leaving, and an LPN had only partially assisted them before directing them to another wing, failing to ensure continuous supervision. The Director of Nursing Services acknowledged that staff were expected to follow care plans, but the investigations into these incidents did not adequately address the failure to adhere to the care plans. The lack of adherence to individualized care plans and insufficient supervision directly contributed to the accidents involving both residents.
Breach of Resident Confidentiality by Staff
Penalty
Summary
The facility failed to ensure the confidentiality and privacy of a resident's personal and medical records. This deficiency occurred when a staff member, identified as Staff C, a Licensed Practical Nurse and Unit Manager, provided a copy of Resident 1's care plan to an unauthorized individual, referred to as CC2. CC2 was not listed as an authorized representative or contact for Resident 1, as confirmed by the facility's records, which showed that CC1 was the resident's Power of Attorney (POA) for Healthcare and Financial matters. Despite this, Staff C handed the care plan to CC2, believing it was permissible to share the information with them. The incident was brought to light during an interview with CC1, who stated that CC2, a visitor to the facility, was given Resident 1's care plan on or about August 14, 2024. CC1, who is the resident's POA, confirmed that CC2 was not authorized to receive any of Resident 1's private or confidential information. The facility's policy on Resident Rights- Privacy and Confidentiality, dated July 2024, mandates the respect of residents' rights to personal privacy and the security of their personal and medical records. This breach of confidentiality placed residents at risk for the loss of privacy and the right to have their preferences honored.
Inadequate Investigation of Resident Incidents
Penalty
Summary
The facility failed to conduct a thorough investigation for two residents, leading to deficiencies in care. Resident 1, who had a history of stroke and left-sided hemiparesis, experienced a fall with significant injury when a CNA, Staff D, assisted the resident without a second CNA as required by the care plan. The investigation incorrectly concluded that Staff D followed the care plan, failing to address the lack of a second staff member and the resident being left unsupported. The Director of Nursing Services (DNS) confirmed that Staff D was aware of the care plan but did not further investigate why the care plan was not followed. Resident 2, diagnosed with hemiplegia and muscle weakness, was found outside the facility by police, indicating an elopement incident. The facility's investigation, conducted by Staff B, did not assess the care plan for transfer or ambulation status, despite the care plan requiring supervision and one-person assistance for transfers and ambulation. The DNS stated that the expectation was for staff to follow care plans, but the investigation did not adequately address the failure to do so.
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.
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What surveyors actually found near you
We read the 151 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) |
|---|---|---|---|---|
| Alderwood Park Health And Rehab Of Cascadia | 1.5 mi | ★★★★★ | 14 | 0 |
| Shuksan Rehabilitation And Health Care | 1.6 mi | ★★★★★ | 5 | 0 |
| North Cascades Health And Rehabilitation | 3.1 mi | ★★★★★ | 45 | 1 |
| Mt Baker Care Center | 4.1 mi | ★★★★★ | 2 | 0 |
| Highland Health And Rehabilitation Of Cascadia | 4.3 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.