Average — CMS composite of the measures below.
A standard survey is most likely before 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 Highland Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
A resident with osteomyelitis, diabetes, and a left-arm PICC line for IV antibiotics experienced harm when an RN used unsterile wound care scissors during a weekly PICC dressing change, cutting the line instead of safely removing the dressing per facility policy. The resident reported bleeding and discomfort, and was emergently transferred to the ED where the PICC was removed and replaced after ultrasound and X-ray. Record review showed the facility’s policy required careful, non-sharp removal of dressings and use of alcohol to loosen adhesive, and the facility’s assessment identified IV and central line care as needed services. Multiple nurses’ competencies for central/PICC/CVAD care and central line dressing changes were past due, and interviews with staff, the resident, and family indicated limited training and frequent problems with IV antibiotic administration and pump management, leading to concerns about staff ability to safely manage the resident’s PICC line.
Surveyors found that the facility repeatedly failed to administer physician‑ordered medications over multiple days because drugs were not available, affecting numerous residents and a wide range of treatments including respiratory, cardiac, thyroid, diabetic, pain, GI, psychiatric, hormone, and supplement therapies. Review of the Medication Not Available report showed that some medications had been previously delivered in 7‑ to 30‑day supplies or were stocked OTC or in the pyxis, yet were still not given, and refill requests were often submitted after supplies should have run out. RNs, LPNs, and agency staff reported frequent shortages of OTC medications, barriers to pyxis access, confusion over who was responsible for ordering, and management discouraging documentation of unavailable meds. Staff described ongoing problems with pharmacy deliveries, late or missing orders, and high‑cost medications requiring administrative approval, while the consulting pharmacist reported a 5–7 day refill turnaround, noted late refill requests, and identified instances where medications should have been on hand or available in pyxis but were not used, resulting in missed doses, including at admission.
A resident’s PICC line was accidentally cut by an RN during a dressing change, leading to transfer to the ED, but the facility did not initiate an incident report or conduct a thorough investigation as required by its abuse prevention and reporting policy. Incident logs contained no entry for the event, and interviews with the interim CNO, a resident care manager, and the interim administrator showed that staff considered the occurrence a mistake, believed education of the nurse was sufficient, or incorrectly assumed an incident report and investigation had been completed. Leadership later stated they would have expected an investigation into what happened, but no formal incident report or documented investigation was found.
The facility did not update and post accurate daily nurse staffing information, including actual nursing hours worked and the current resident census, for an extended period. Surveyors repeatedly observed that the posted staffing sheet displayed an outdated date, and an interim CNO confirmed that the posting had not been updated as required. This failure prevented residents and visitors from readily viewing current nurse staffing levels.
A resident at risk for pressure injuries did not receive consistent preventive interventions, such as off-loading heels and use of heel protective devices, as outlined in the care plan. Documentation showed these measures were not regularly implemented, resulting in the development of a deep tissue injury on the resident's heel, significant discomfort, and improper wound care practices by staff.
The facility failed to maintain a safe, clean, comfortable, and homelike environment. A resident reported being sent to bed without clean sheets, staff and family described ongoing linen shortages, and inventory showed limited supplies. Surveyors also observed a bed in one room without a mattress, a resident curtain left broken and unsecured, strong urine and feces odors in the halls, and the dining room cluttered with soiled dish carts and damaged flooring.
Improper Storage and Dating of Insulin: Insulin pens and bottles were found improperly stored and undated in both the North and South med carts. A RN observed Glargine insulin kept outside the refrigerator in individualized bags, an open bottle that was expired, and multiple insulin pens without dates showing when they were opened or removed from refrigeration. Staff stated insulin should be dated and is good for 28 days after opening or removal from the refrigerator.
NAC Annual Reviews and In-Service Training Not Completed: The facility failed to complete annual performance reviews for several NACs and did not ensure multiple NACs received the required 12 hours of annual in-service training. Documentation showed that several staff had only a portion of the required education hours, and the Administrator and HR/Payroll Coordinator confirmed the reviews and training hours were incomplete.
Staff did not consistently perform hand hygiene during meal tray delivery, failed to use appropriate PPE when caring for a resident on enhanced precautions, and did not properly store or maintain oxygen and nebulizer equipment for a resident. These lapses were observed during direct care activities and confirmed through staff interviews and record review.
A resident reported missing seven pairs of rubber pants and said the issue had been told to multiple staff members, but the grievance log had no entry for the complaint. The DON, resident care manager, and an RN were unaware of the issue, while a laundry aide acknowledged the report but did not complete a grievance form and did not know how to do so; the laundry supervisor stated missing items should be placed on a grievance form and tracked.
Failure to follow ordered medication parameters affected three residents. One resident with DM2 had repeated BG readings above ordered limits, another resident had BP medication given despite low DBP and no provider notification documented, and a third resident with HTN received metoprolol even when SBP was below the hold parameter. Staff stated meds outside ordered vital sign parameters should be held, the provider notified, and the event documented.
A resident who preferred two showers weekly reported not having had a shower in about a month and needed beard trimming that staff only provided with showers. The care plan directed staff to give a bed bath if a shower could not be tolerated, but the record showed only a few showers, two shower refusals, and two NA entries with no documentation of a bed bath. Staff reported documentation errors and lack of time, and the CNO was unaware the resident had gone without a shower since mid-month.
Pharmacy recommendations were marked as noted by an RCM, but two residents' records did not show the recommendations were completed. One resident on an antipsychotic lacked current AIMS documentation, and another resident on a psychoactive PRN medication had no stop date or completed record of the 14-day review. The DON stated the RCMs were given monthly pharmacy recommendations to ensure provider review and timely completion.
A resident with a history of hypersexuality and inappropriate touching was inadequately supervised, resulting in inappropriate contact with another resident who had dementia. Despite having a care plan to manage these behaviors, the facility failed to document and implement necessary interventions, leading to a lapse in supervision and protection.
The facility failed to provide adequate nursing staff, resulting in unmet needs for three residents. A resident with severe cognitive impairment was found undressed and unable to reach their call light or drinks. Another resident, at risk for falls, reported long delays in call light responses, leading to accidents. A third resident, also at risk for falls, had their call light turned off without assistance, prompting unsafe self-transfer attempts. Staff confirmed insufficient staffing levels.
The facility failed to meet professional standards in medication administration and physician consultations. During an internet outage, printed MARs were incomplete, leading to potential medication errors for residents. Staff relied on pharmacy labels instead of accurate physician orders. Additionally, a resident's GI specialist referral was not completed, despite a physician's order, leaving the resident's symptoms unaddressed.
The facility failed to ensure that NACs had the necessary competencies to provide nursing services, as five staff members lacked documented assessments of their skills. Despite policies requiring validation of competencies, interviews revealed that these assessments were not completed, placing residents at risk for unmet care needs.
A facility failed to comply with infection control guidelines during medication administration and laundry handling. An LPN did not use barriers or perform hand hygiene while administering medications, and the laundry room lacked procedures for handling contaminated linens. The infection control program had not been reviewed since 2022, and staff were not adequately trained.
The facility did not ensure residents had access to Saturday mail deliveries, impacting two residents. Despite the facility's policy on communication rights, mail delivered on Saturdays was not distributed until Mondays. This was confirmed by staff interviews, with one resident having moderate cognitive impairment and another with no cognitive impairment reporting the delay.
The facility failed to ensure comprehensive Resident Assessment Instrument (RAI) summaries for three residents, leading to incomplete care planning. A resident's significant change MDS assessment lacked input from their representative and comprehensive assessments in key areas. Another resident's annual MDS assessment was similarly deficient. Additionally, a resident's dental issue was not properly documented, preventing necessary care coordination. Staff interviews revealed remote MDS completion and inadequate CAA documentation.
A facility failed to provide appropriate care for a resident with an indwelling urinary catheter, increasing the risk of CAUTIs. The facility did not develop individualized plans for catheter care, instead following routine procedures for changing and flushing the catheter system, contrary to CDC guidelines and facility policy. The resident, with a chronic suprapubic catheter, was readmitted after a UTI, and observations showed potential issues with catheter care. Staff confirmed routine practices were not aligned with best practices, and the resident was not informed of the infection risk.
The facility failed to prevent unnecessary drug administration for two residents. One resident received PRN pain medication without documented non-pharmacological interventions, despite having a care plan requiring such attempts. Another resident with IBS and frequent diarrhea was given bowel medications that were supposed to be held for loose stools, resulting in unnecessary administration. Staff interviews confirmed these oversights.
A facility failed to maintain accurate clinical records for a resident with a chronic suprapubic catheter. Despite an order to measure and record urinary output every shift, documentation was missing for six shifts. An LPN was unable to provide information about the missing records.
A facility failed to implement its Antibiotic Stewardship Program effectively, as demonstrated by a resident who was prescribed antibiotics without documented clinical indication or validation of an active infection. Interviews with staff revealed a lack of communication and verification processes, highlighting deficiencies in the program's execution.
The facility did not ensure that NACs completed the required 12 hours of annual training. Two NACs, hired in 2022 and 2023, did not meet the training requirement, with one lacking documentation and the other completing only 6.10 hours. This was confirmed by the DNS during an interview.
A resident with diabetes mellitus type 2 experienced a hypoglycemic episode with a blood glucose level as low as 47 mg/dL. Despite having a continuous glucose monitoring system, the incident was not documented, and the physician was notified 26 days later. The resident sought help independently after the glucose monitor alarmed, and staff inconsistencies in reporting and documentation were noted. The facility lacked a policy for using the monitoring system, leading to a deficiency in diabetic management.
The facility failed to address the behavioral health needs of a resident with multiple diagnoses, including hip fracture and adjustment disorder. Despite ongoing confusion, restlessness, and refusal of care, the facility did not implement effective person-centered interventions. Observations and interviews revealed the resident's distress and unmet needs, with staff failing to respond to calls for help and adequately document behavioral health issues.
The facility failed to provide timely pharmacy services for three residents upon admission, resulting in delayed administration of critical medications for pain management, diabetes, leukemia, and Parkinson's disease. Staff inconsistencies and lack of proper documentation contributed to these deficiencies.
The facility failed to maintain a clean and sanitary shower room, leading a resident to avoid bathing due to the filthy conditions, including black grout and debris. Staff confirmed minimal cleaning practices and acknowledged built-up grime and a non-functional tub.
Improper PICC Line Dressing Change and Inadequate Nurse Competencies
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate administration of IV therapy by not following professional standards and aseptic technique during a PICC line dressing change for Resident 20. The facility’s own 2025 Facility Assessment identified that its resident population required nursing care for IV peripheral and central lines, and that competencies were to be monitored through leadership rounding, mentoring, skills checks, and annual staff competencies. The facility had a policy for central venous access device dressing changes that required careful removal of old dressings, stabilizing the catheter to minimize movement, and using alcohol to loosen adhesive. Resident 20 was admitted with osteomyelitis of the thoracic and lumbar vertebrae, type 2 diabetes, and vancomycin resistance, and had a PICC line in the left upper arm with care plan interventions for enhanced barrier precautions and dressing changes to maintain patency and keep the site infection-free. During a scheduled weekly PICC line dressing change, the nurse performing the procedure used general wound care scissors, which were unsterile, to cut tape on the dressing. The nurse reported attempting to cut the tape and believed they had cut the dressing, but the PICC line was in fact cut. The resident and collateral contact reported that the nurse took scissors from their scrub pocket and cut near the line while trying to remove “gummy stuff” from the dressing. After the dressing was mostly removed and a new dressing placed over the insertion site, the resident noticed bleeding and felt blood under the armpit. The nurse initially stated the line had “broke” or “snapped,” while the resident asserted that it had been cut. The facility’s progress note documented that the PICC line was accidentally cut during the dressing change and that a pressure dressing was applied before the resident was transferred emergently to the emergency department for PICC line replacement and additional diagnostic procedures, including ultrasound and X-ray. Interviews and record review showed that licensed nurse competencies related to central/PICC/CVAD care and central line/midline dressing changes for multiple nurses were past due as of the review date. One RN stated they were unaware of any in-service instructing staff not to use scissors during PICC line dressing changes, though they knew sharps should not be used. The RN who cut the line stated they had not received much training at the facility, were previously certified to insert IVs at another facility, and felt unsupported due to lack of education. The resident, their family member, and staff interviews indicated that few nurses were comfortable or experienced with PICC line care, that staff had difficulty managing IV antibiotics, IV pumps, and air bubbles, and that the resident’s PICC line care appeared problematic throughout the stay. The facility’s failure to ensure current nurse competencies and adherence to its own PICC dressing change policy resulted in the use of unsterile scissors during a PICC line dressing change, cutting the line and necessitating emergency transfer and replacement of the central line, and placed the resident at serious risk for central line–associated bloodstream infection as stated in the report. The report also documents that the resident and their family perceived that staff did not know how to care for the PICC line or administer IV antibiotics properly. The family member stated it appeared there was only one nurse who knew how to work with a PICC line and described wasted IV antibiotic while staff attempted to remove air bubbles, as well as a dropped and broken medication vial. The resident reported that staff repeatedly had problems with the IV pump jamming, excessive air bubbles, and understanding how the antibiotics were to be infused, and that staff told them they were the only resident with an IV like theirs. The resident described the nurse’s visible panic after cutting the line and uncertainty about what to do next, including the nurse asking about resuscitation preferences while the resident was bleeding and waiting for emergency services. These observations and statements, combined with the documented lapse in competencies and deviation from the facility’s dressing change procedure, form the factual basis for the cited deficiency.
Widespread Failure to Provide Ordered Medications Due to Stock, Ordering, and Coordination Breakdowns
Penalty
Summary
The deficiency involves the facility’s failure to provide all physician‑ordered medications to residents on 13 of 14 reviewed days for 20 residents, disrupting continuity of care and placing residents at risk of not having their medical needs met. Review of the facility’s Medication Not Available report for 01/30/2026 through 02/12/2026 showed numerous prescribed medications, including anticonvulsants, respiratory medications, gastrointestinal medications, antidepressants, antiplatelet agents, thyroid medications, diabetic medications, cardiac medications, hormone therapies, pain medications, supplements, and OTC products, were not administered because they were not available. The report also documented that some medications were available in the facility’s pyxis machine or should have been available as OTC facility stock, yet were still not given. The Medication Not Available report detailed repeated instances where residents’ medications were not administered despite prior deliveries or available stock. Examples included residents missing doses of gabapentin, albuterol inhalation, fluticasone‑salmeterol inhalers, metronidazole topical cream, ranitidine, duloxetine, levothyroxine, semaglutide, clopidogrel, diltiazem, oxybutynin, pantoprazole, estradiol, alendronate, and various vitamins, minerals, and protein supplements. In several cases, the pharmacy had delivered 7‑, 14‑, 28‑, or 30‑day supplies on earlier dates, but the medications were still documented as unavailable later, and refill requests were sometimes submitted after the expected depletion date. The consulting pharmacist later confirmed that many of the medications listed should have been on hand based on previous delivery dates and that some medications were available in pyxis at the time they were reported as not administered. Staff interviews described systemic problems with obtaining both pharmacy‑dispensed and OTC medications, as well as confusion and breakdowns in responsibility for ensuring medication availability. Nursing staff, including RNs and LPNs, reported that OTC medications were often not available, that management discouraged documenting unavailable medications, and that they were directed to speak with the Administrator or HR, who in turn reported not having a card to purchase needed OTC items. Agency nurses reported they could not access the pyxis and had to rely on regular staff to obtain medications, and that notifications to Resident Care Managers did not always result in orders being placed. Nursing staff and managers described ongoing issues with pharmacy deliveries, including medications not arriving despite being ordered, delays related to ordering cut‑off times, and high‑cost medications requiring administrative approval and signatures. The contracted pharmacist stated they were unaware of delivery difficulties, noted a 5–7 day refill turnaround time, and identified late refill requests and missed admission doses where orders were submitted late in the day and no rush requests were made, contributing to the pattern of unavailable medications. Additional interviews with leadership and clinical staff further illustrated the lack of clarity and follow‑through in the medication supply process. An interim CNO stated they did not know where the disconnect was in having medications available. A Resident Care Manager acknowledged continuous issues with the pharmacy and stated that medications listed on the Medication Not Available report were simply not available, whether pharmacy‑delivered or facility‑supplied OTCs, and that the problem had been ongoing. Nursing staff reported that when medications were not available for a day or two, they tried to notify providers, and that they often had to call the pharmacy multiple times, sometimes being told that medications had not been ordered even when staff believed they had been. The consulting pharmacist’s follow‑up email also noted that several medications on the report should have been available as OTC stock, that many should have been on hand based on prior deliveries, that refill requests were often delayed beyond the expected depletion date, and that for one admission, multiple ordered medications were available in pyxis but not used, and no rush request was submitted for the remaining medications, resulting in missing doses on the evening of arrival.
Failure to Investigate PICC Line Injury Incident
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete and thorough investigation of an incident in which a resident’s peripherally inserted central catheter (PICC) line was accidentally cut by an RN during a dressing change, resulting in the resident being sent to the emergency department. The facility’s abuse prevention and reporting policy required investigation of events suggesting possible abuse or neglect and documentation of such events, including appropriate corrective action if an allegation was verified. However, review of the facility’s incident logs for January and February 2026 showed no incident related to this PICC line event, despite a progress note documenting that the PICC line was accidentally cut and the resident was transferred to the hospital. Interviews with multiple staff revealed that no incident report or formal investigation was initiated at the time of the event. The interim CNO acknowledged that no incident report was completed because the resident was discharged home from the hospital and stated they were only going to complete an incident report on the day of the survey. The interim CNO also reported that, after reviewing internal guidance (“Purple Book”) with the intradisciplinary team, they had determined the event did not meet the definition requiring an incident report. A resident care manager stated that incident reports were usually started by the cart nurse or nursing managers, but in this case they were never directed to complete one and viewed the event as a mistake for which the nurse was educated. The interim administrator believed an incident report existed in the risk management system or had been reviewed in stand-up, but none was found, and stated they would have expected an investigation. The company lead CNO also stated they had been told an investigation was being conducted and would have expected one to be done.
Failure to Update and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate daily nurse staffing information, including the total number of actual nursing hours worked and the resident census, for a continuous period from 01/07/2026 through 02/13/2026, totaling 37 days. Surveyor observations on 02/11/2026 at 12:22 PM and on 02/12/2026 at 12:40 PM showed that the daily nurse staffing posting remained dated 01/07/2026. During an observation and interview on 02/13/2026 at 3:10 PM, the Interim Chief Nursing Officer confirmed that the nurse daily staffing posting was still dated 01/07/2026 and acknowledged that it should be updated daily to reflect the actual nurse staffing hours and the facility’s current census. This failure prevented residents and visitors from being able to readily view current nurse staffing information.
Failure to Implement Pressure Injury Prevention Leading to Deep Tissue Injury
Penalty
Summary
A resident with a history of fractured left hip, morbid obesity, and neuropathy was admitted to the facility without any existing pressure injuries but was identified as being at risk for developing them due to limited mobility and incontinence. The care plan specified the use of heel protective devices and off-loading of heels when in bed, and the initial skin inspection documented that green heel boots were placed on both feet. However, subsequent documentation and direct care staff records showed that these interventions were not consistently implemented or documented, and there was no evidence that the resident's heels were off-loaded or that heel protective devices were used as required. Over the course of the resident's stay, staff noted a boggy/soft spot on the left heel, which remained closed and painless initially. Despite this early sign, there was no documentation of preventive interventions being carried out. The resident eventually developed a large, closed blister on the left heel, which was later identified as a deep tissue injury (DTI). The root cause analysis indicated that the injury was due to the resident's heel rubbing on the bed, exacerbated by immobility and the use of a bed that was too small for proper positioning. Interviews and emails from a collateral contact and staff confirmed that heel boots were often not applied, and the resident's heels were observed rubbing against the bed, leading to further skin breakdown. The resident reported significant discomfort and pain from the heel wound, which interfered with rehabilitation efforts. Additional concerns were raised about improper wound care, including staff peeling back dead skin and applying socks over the open wound, which became stuck to the wound. Staff interviews confirmed lapses in documentation and implementation of ordered interventions, and the resident's care records did not reflect consistent use of off-loading boots or other preventive measures as outlined in the care plan.
Unsafe and Uncomfortable Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment on two units and in the main dining room. The report cited a lack of clean linens, unpleasant odors in the halls, broken or incomplete resident room furnishings, and dining room conditions that were not comfortable. The deficiency was identified under WAC 388-97-0880(1)(2). Resident 14 reported that staff told them there were no clean sheets available and that they had to go to bed using a draw sheet instead of a regular sheet. Family and staff also reported ongoing linen shortages, with one family member stating there were often not enough linens for bed changes and staff saying the facility was short on linen almost daily. The laundry supervisor and laundry aide described ongoing linen inventory issues, including linens being stashed in resident rooms and orders pending, while staff also reported that night shift had voiced running out of clean linen. The inventory review showed limited quantities of several linen items compared with the census of 33 residents. The report also documented resident room and environmental concerns. A bed in room 9B was observed multiple times without a mattress on the frame, and maintenance staff stated the bed was broken and the mattress had been removed, though they did not know why. In Resident 4’s room, the left curtain was repeatedly observed unhooked with curtain rings on the nightstand or table, and staff were overheard saying the curtain could not be closed and maintenance would be told. The resident’s curtain was later observed fixed and hanging appropriately. In addition, strong urine and feces odors were observed in the hallways on multiple occasions, and the dining room had blocked areas, soiled dish carts, and flooring that was separating at the seams with visible gaps.
Improper Storage and Dating of Insulin
Penalty
Summary
The facility failed to ensure proper storage and labeling of insulin in 2 of 2 medication carts, the North and South carts, during observation, interview, and record review. On the South medication cart, three Glargine insulin pens were observed in individualized plastic bags and stored outside of the refrigerator. Resident 4’s Glargine insulin pen had no date showing when it was opened or removed from the refrigerator. Resident 26 had an open bottle of Glargine insulin dated 07/04/2025 and an undated Glargine insulin pen. Staff D could not locate dates on the insulin pens and stated the bottle was expired. Staff D also stated Glargine insulin is good for 28 days when removed from the refrigerator and when opened. On the North medication cart, Resident 43’s Glargine insulin pen was observed stored in the medication cart without a date. Staff C stated insulin is good for 28 days when pulled from the refrigerator and said Resident 43’s insulin pen should have been dated. In interview, Staff B, Chief Nursing Officer, stated insulin is good for 28 days and should be dated when removed from the refrigerator and opened. Review of Resident 4’s physician order showed Glargine insulin 20 units subcutaneously daily, and Resident 26’s physician order showed Glargine insulin 10 units daily.
NAC Annual Reviews and In-Service Training Not Completed
Penalty
Summary
The facility failed to develop, implement, and maintain a process to ensure annual performance reviews were completed for 3 of 5 staff reviewed, identified as Staff P, Q, and R. The facility assessment stated that the Staff Development Coordinator monitored required education and education hours for staff, and that education and training would include areas of weakness identified through NAC annual performance reviews. However, the facility provided documentation showing that Staff P, Staff Q, and Staff R did not have annual performance reviews completed. The facility also failed to ensure that NAC staff received the required 12 hours of annual in-service training for 4 of 5 staff reviewed, identified as Staff O, P, Q, and R. Documentation showed Staff P had 4.25 hours of in-service training, Staff Q had 4 hours, Staff R had 1.5 hours, and Staff O had 4.25 hours. During interviews, the Administrator confirmed that staff performance evaluations and required 12 hours of education were not complete, and the Human Resources/Payroll Coordinator confirmed that Staff P, Q, and R did not have performance reviews completed and that the documented education hours for Staff O, P, Q, and R were the facility’s recorded annual in-service hours.
Infection Control Failures in Hand Hygiene, PPE Use, and Respiratory Equipment Maintenance
Penalty
Summary
Staff failed to comply with infection prevention and control guidelines, as evidenced by multiple observations of a nursing assistant not performing hand hygiene during meal tray delivery. The staff member was seen handling meal trays, touching residents’ personal items and silverware, and assisting with resident care activities without performing hand hygiene before or after these tasks. The staff member also did not demonstrate knowledge of when hand hygiene should be performed during meal pass, and admitted to not performing hand hygiene while passing lunch trays. In another instance, a staff member did not use appropriate personal protective equipment (PPE) when providing care to a resident on enhanced based precautions (EBP) due to an indwelling device. The staff member only wore gloves, despite facility policy and signage indicating the need for additional PPE such as gowns, masks, and eye protection during high-contact care activities. The staff member was unable to explain the purpose of EBP or when it should be implemented, and reported only using gloves when assisting the resident with toileting. Additionally, the facility failed to ensure proper storage and maintenance of oxygen and nebulizer tubing for a resident. Observations revealed that oxygen tubing and a nasal cannula were left touching the floor or stored inappropriately, and nebulizer equipment appeared dirty, was not dated, and was not stored in a plastic bag. Staff interviews indicated inconsistent practices regarding labeling, dating, and storing respiratory equipment, and documentation of tubing changes was not found in the treatment administration record.
Failure to Process Resident Grievance for Missing Clothing Items
Penalty
Summary
The facility failed to initiate, investigate, and resolve a grievance for one sampled resident who reported missing seven pairs of rubber pants for two weeks. The resident stated they had reported the missing items to at least four or five staff members and identified that only one laundry aide was allowed to take and launder their clothing. Review of the grievance log from February 2025 through July 2025 showed no logged entries for the resident’s missing rubber pants. During interviews, the DON and the resident care manager stated they were not aware of the missing rubber pants, and an RN stated they had not received any reports from the resident about the missing items. The laundry aide stated the resident had reported the missing rubber pants, that the resident currently had one pair remaining, and that they did not fill out a grievance form and did not know how to do it. The laundry supervisor stated that if a resident was missing an item, it needed to be put on a grievance form and tracked.
Failure to Follow Medication Parameters and Notify Providers
Penalty
Summary
The facility failed to ensure professional standards of quality were met for 3 of 5 residents reviewed for unnecessary medication review. For Resident 3, who was readmitted with diabetes mellitus type 2 and reported being prescribed insulin to manage diabetes, the July 2025 MAR showed an order to check blood glucose before meals, initiate low blood sugar protocols and notify the provider if blood glucose was less than 70, and notify the provider and follow directives if blood glucose was above 300. The record showed blood glucose values above 349 on multiple dates in July and August 2025, including 365, 385, 542, 383, 354, 558, 350, and 358, and the report states the MAR also showed blood glucose less than 70 and notification requirements. For Resident 6, the MAR showed blood pressure medication should have been held 24 of 31 days in July and on 08/01-08/03/2025 because diastolic blood pressure was less than 70, but the EMR contained no documentation that the provider was notified of low DBP, high blood glucose, or that blood pressure medication was held per physician orders. For Resident 26, who was admitted with primary hypertension, the physician ordered metoprolol tartrate 37.5 mg twice daily with instructions to hold if systolic blood pressure was less than 120 or heart rate was less than 60 bpm. Review of the EMAR showed the resident's systolic blood pressure was less than 120 on 4 of 31 days in July 2025, 10 of 30 days in June 2025, and 9 of 31 days in May 2025, yet the licensed nurse administered the medication. Staff interviews stated that when vital signs were outside ordered parameters, the medication should not be given, the physician should be notified, and the event should be documented in the medical record. The facility policy stated medication should be administered per physician orders and manufacturer directives, with vital sign parameters and side effects monitored as indicated.
Failure to Provide Scheduled Bathing and Hygiene Care
Penalty
Summary
The facility failed to ensure adequate bathing for Resident 13, who preferred two showers each week and, if unable to tolerate a shower, was to receive a bed bath per the resident’s Kardex. Resident 13 was admitted to the facility on [DATE] and, during an interview on 08/04/2025, reported not having had a shower in the last month and stated they needed their beard trimmed, which staff only did when showers were provided. The resident was noted to have a long beard. Review of the last 30 days of bathing documentation showed showers were provided on 07/08/2025, 07/12/2025, and 07/15/2025. The record also showed shower refusals on 07/29/2025 and 08/02/2025, and two entries marked Not applicable/Not attempted on 07/22/2025 and 07/26/2025. There was no documentation that a bed bath was provided when showers were not completed. Staff Q stated the 07/29/2025 refusal entry was an error and that Resident 13 had not refused showers from them recently. Staff K stated they ran out of time on the shifts when the NA entries were documented and could not complete the resident’s shower. The Chief Nursing Officer reported being unaware that Resident 13 had not received a shower since 07/15/2025.
Pharmacy recommendations not completed in resident records
Penalty
Summary
The facility failed to ensure pharmacy recommendations were completed in the medical record for 2 of 6 residents reviewed for unnecessary medications. The facility policy titled, Pharmacy Services, stated the facility would collaborate with the pharmacist in a timely manner to develop and implement pharmaceutical services, and the policy titled, Unnecessary medications, stated that residents receiving antipsychotic medications would have AIMS testing and that psychoactive medications should be evaluated after 14 days after admission or start date. Resident 26 was prescribed an antipsychotic medication three times a day, and the pharmacy recommendation dated 07/11/2025 noted that an AIMS test had not been conducted and was overdue. The nurse practitioner agreed it needed to be completed, and the document was later marked with unknown initials dated 08/01/2025. However, review of the medical record on 08/07/2025 showed the last AIMS was completed in January 2025, and Staff H was unable to locate documentation that the recommendation had been completed in the record. Resident 30 was prescribed an antidepressant medication every four hours as needed with a start date of 06/15/2025 and no end date. The pharmacy recommendation dated 07/11/2025 noted the resident had been on a psychoactive medication past the 14-day evaluation date and asked for a new duration and rationale; the provider agreed to a 14-day duration and documented the rationale, and the document was later marked with unknown initials dated 08/01/2025. However, review of the medical record on 08/07/2025 showed the medication still had a start date of 06/15/2025 and no end date, and Staff H was unable to locate documentation that the recommendation had been completed in the record.
Inadequate Supervision Leads to Resident-to-Resident Contact
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with a history of hypersexuality and inappropriate touching, leading to a resident-to-resident sexual contact. Resident 1, who had diagnoses including Parkinson's disease, dementia, and other behavioral disturbances, was on medications known to have side effects that could exacerbate impulsive behaviors. Despite having a care plan in place to manage these behaviors, the facility did not effectively implement the necessary interventions to prevent inappropriate interactions. Resident 1's care plan included interventions such as diverting attention, removing them from situations, and offering activities to minimize disruptive behaviors. However, documentation showed multiple episodes of sexually inappropriate behavior by Resident 1 that were not recorded in the nursing progress notes. This lack of documentation and follow-through on the care plan interventions contributed to the failure to prevent the incident of inappropriate contact with Resident 2, who had dementia and was unable to consent. Interviews with staff revealed that there was a lack of consistent supervision and intervention when Resident 1 was around other residents, particularly female residents. Staff were aware of the need for enhanced supervision but did not consistently maintain line of sight or redirect Resident 1 as required. This oversight allowed Resident 1 to engage in inappropriate contact with Resident 2, highlighting a significant lapse in the facility's duty to protect residents from harm.
Insufficient Nursing Staff Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by the experiences of three residents. Resident 1, who has severe cognitive impairment and is dependent on staff for personal care, was found in a state of undress with their call light and drinks out of reach. Despite the resident's known behavior of rejecting care and language barriers, the situation was not addressed promptly, leaving the resident's needs unmet. Resident 2, who has no cognitive impairment but is at risk for falls due to impaired mobility, reported that their call light went unanswered for over an hour, resulting in an accident. The facility's investigation attributed this to staff miscommunication during breaks. The resident expressed that delays in responding to call lights were frequent, indicating a systemic issue with staffing levels. Resident 4, who has a history of falls and requires assistance for mobility, experienced a similar issue. Their call light was turned off without their needs being addressed, leading them to attempt self-transfer, which is against their care plan. Staff interviews confirmed that there was insufficient staffing to meet residents' needs, with some staff being pulled from their designated duties to cover shortages.
Medication Administration and Physician Consultation Deficiencies
Penalty
Summary
The facility failed to ensure professional standards were met in medication administration and physician consultations, leading to deficiencies in care. During an internet outage, the facility resorted to using printed medication administration records (MARs) instead of electronic records. However, the printed MARs were incomplete, with the first letters of each medication cut off, making it difficult for licensed staff to accurately administer medications. This issue was observed on both the North and South Halls, affecting multiple residents, including Resident 13 and Resident 10. Staff were observed administering medications based on incomplete MARs, relying on pharmacy labels to verify medication orders, which were not a reliable source for confirming physician orders. Resident 13 was administered medications with incomplete MARs, where the names of medications were partially missing, leading to potential medication errors. Staff involved in the medication pass were unaware of the printing issue until it was brought to their attention. Similarly, Resident 10's medication administration was compromised due to the incomplete MARs, with missing parts of physician orders such as medication names, routes, doses, and directions. Staff had to rely on medication labels to identify the correct medications, which posed a risk of errors. Additionally, the facility failed to follow through on a physician's order for a specialist referral for Resident 27, who was experiencing chronic diarrhea. Despite the physician's note indicating the need for a gastrointestinal (GI) specialist consultation, the order was not completed. Staff were unaware of the consultation order, and the resident continued to experience symptoms without appropriate specialist intervention. This oversight further highlights the facility's failure to adhere to professional standards and ensure residents' needs were met.
Failure to Ensure Competency of Nursing Assistants
Penalty
Summary
The facility failed to ensure that Nursing Assistants Certified (NACs) possessed the necessary competencies, skills, and proficiencies to provide nursing and related services to residents. This deficiency was identified during interviews and record reviews, where it was found that five sampled staff members (Staff H, I, Q, R, and S) did not have documented assessments of their competencies to provide nursing services. The facility's policy, dated November 28, 2017, required validation of nurse aides' competencies in skills and techniques, but this was not adhered to. The facility's assessment, dated July 26, 2023, to July 25, 2024, indicated that education was provided through orientation, monthly competencies, and annual skills fairs, with monitoring through senior leader rounding and mentorship programs. However, interviews with Staff B, a Registered Nurse/Clinical Resource Nurse, and Staff A, the Director of Nursing Services, revealed that competencies for the staff had not been completed, and no documentation could be located for the five staff members. This lack of competency assessment placed residents at risk for unmet care needs and a diminished quality of life.
Infection Control Deficiencies in Medication Administration and Laundry Handling
Penalty
Summary
The facility failed to ensure compliance with Infection Prevention and Control Guidelines during medication administration by a Licensed Practical Nurse (LPN). The LPN did not use a barrier when placing medication items on a resident's bed and over the bed table, and failed to perform hand hygiene before and after administering medications, including insulin and nasal spray. The LPN admitted to forgetting to use a barrier and only performed hand hygiene after leaving the resident's room. In the laundry room, the facility did not have a system in place for handling potentially contaminated linens to prevent cross-contamination. The housekeeping attendant was observed sorting and loading dirty linen without a clear procedure for cleaning the washing machines between loads. The laundry room was cluttered, with limited space for clean linen, and the machines were covered in dust and debris. The housekeeping manager, recently promoted, was unaware of any infection control procedures related to laundry. The facility's infection control program had not been reviewed or revised since October 2022, and no risk assessment had been conducted. The Infection Preventionist acknowledged the lack of a risk assessment and the failure to educate staff on proper infection control practices. The Director of Nursing Services was unaware of the deficiencies in the infection control program and the lack of training for the housekeeping manager.
Failure to Provide Saturday Mail Access
Penalty
Summary
The facility failed to ensure residents had access to Saturday mail deliveries, affecting two of the six sampled residents. According to the facility's policy on Resident Rights, residents are entitled to private and unrestricted communication, including the right to receive sealed, unopened correspondence. Resident 27, who has moderate cognitive impairment, reported receiving an email notification about mail delivery on Saturday but was unable to access the mail until later. Resident 2, with no cognitive impairment, confirmed that while the postal service delivers mail on Saturdays, it is not distributed to residents until Mondays. Staff interviews corroborated that mail is retrieved on weekends but not distributed until the following Monday, as confirmed by Staff M from the Business Office and Staff N, a Hospitality Aide.
Deficiencies in Resident Assessment and Care Planning
Penalty
Summary
The facility failed to ensure that the Resident Assessment Instrument (RAI) included comprehensive summaries of the Care Area Assessments (CAA) for three residents, which are essential for analyzing and planning individualized care. For Resident 4, the significant change Minimum Data Set (MDS) assessment did not include input from the resident's representative and lacked a comprehensive assessment of the resident's needs, strengths, goals, life history, or preferences in areas such as cognitive loss/dementia, behavioral symptoms, mood state, and psychotropic drug use. Similarly, for Resident 9, the annual MDS assessment was missing input from the resident's representative and did not provide a comprehensive assessment in the cognitive loss/dementia and psychotropic drug use CAAs. Resident 33 experienced issues with their upper denture not fitting, which was not addressed in the admission MDS dental section, leading to the Dental CAA not being triggered or completed. This oversight occurred despite the resident's care plan indicating the need for dental care coordination. Interviews with staff revealed that the MDS assessments were completed remotely, and there was a lack of comprehensive documentation in the CAAs, with some staff unaware of the issues until recently. The failure to properly assess and document the residents' needs placed them at risk of not receiving appropriate services based on their individualized needs.
Inadequate Catheter Care Increases Risk of CAUTIs
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to an increased risk of catheter-associated urinary tract infections (CAUTIs). The facility did not develop individualized plans for the prevention of CAUTIs, including specific clinical indications for changing catheters and catheter bags. Instead, the facility followed routine procedures for changing catheters and flushing the catheter system, which is contrary to the guidelines provided by the Centers for Disease Control (CDC) and the facility's own policy. These guidelines recommend changing catheters and drainage bags based on clinical indications such as infection or obstruction, rather than at routine, fixed intervals. Resident 3, who had a chronic suprapubic catheter due to a neuromuscular dysfunction of the bladder, was readmitted to the facility after hospitalization for a urinary tract infection. Observations revealed that the resident's urine was dark yellow with sediment, indicating potential issues with catheter care. The facility's records showed that the resident's catheter was changed monthly and flushed three times a week without documented clinical indications. Interviews with staff confirmed that these routine practices were not aligned with best practices for preventing CAUTIs, and the resident was not informed about the increased risk of infection due to these practices.
Failure to Prevent Unnecessary Drug Administration
Penalty
Summary
The facility failed to ensure that Resident 10's drug regimen was free from unnecessary medications by not documenting the use of non-pharmacological interventions before administering PRN pain medication. Resident 10, who was admitted with severe cognitive impairment and diagnoses including cancer of the pancreas and malignant neuroendocrine tumors, had a care plan that required non-pharmacological interventions to be attempted prior to administering Morphine Sulfate for pain. However, records from June and July 2024 showed multiple instances where the medication was administered without documentation of such interventions. Interviews with staff indicated that while non-pharmacological methods were reportedly attempted, they were not consistently documented as required. Additionally, the facility failed to follow hold orders for bowel medications for Resident 3, who had irritable bowel syndrome with diarrhea. Despite the resident experiencing frequent diarrhea, facility nurses continued to administer Senna and Docusate Sodium, which were ordered to be held in the presence of loose stools. This resulted in the resident receiving unnecessary bowel medications. Interviews with staff confirmed that the medications should have been held according to the orders, but this was not done, leading to the administration of 29 doses of Senna and 56 doses of Docusate Sodium unnecessarily.
Failure to Document Urinary Catheter Output
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who was reviewed for urinary catheter care and services. The resident, who had no cognitive impairment and was diagnosed with neuromuscular dysfunction of the bladder, was readmitted to the facility after hospitalization for a urinary tract infection secondary to a chronic suprapubic catheter. An order was placed on the resident's Treatment Administration Records (TARs) to measure and record the indwelling catheter urinary output every shift for hydration purposes. However, from July 14 to July 25, 2024, there was no documentation of urinary output for six shifts. During an interview, a Licensed Practical Nurse/Resident Care Manager was unable to provide information about the missing documentation for these six shifts and stated they would need to look into it, but no additional information was provided.
Failure in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) effectively, as evidenced by the case of Resident 3. Resident 3 was readmitted to the facility after a hospitalization for a urinary tract infection (UTI) related to a chronic suprapubic catheter. Upon discharge, the resident was prescribed amoxicillin-clavulanate, an antibiotic, to be taken twice daily for five days. However, the facility's medical records lacked any clinical indication, laboratory, or culture results to justify the use of this antibiotic. There was no analysis or validation to confirm the presence of an active infection, which is a critical step in the ASP to prevent unnecessary antibiotic use. Interviews with facility staff revealed gaps in the ASP's implementation. Staff G, the LPN/Infection Preventionist, acknowledged their responsibility to ensure proper antibiotic usage and indication but admitted to being unable to locate any documentation or analysis for Resident 3's antibiotic use. Furthermore, Staff A, the Director of Nursing Services, was unaware that the prescribed antibiotic for Resident 3 had not been reviewed for proper indication. This oversight indicates a failure in the communication and verification processes between the infection preventionist, resident care manager, and providers, which are essential components of the ASP.
Deficiency in NAC Annual Training Hours
Penalty
Summary
The facility failed to develop, implement, and maintain an in-service training program to ensure that Nursing Assistants Certified (NACs) received the required 12 hours of annual training. Specifically, two NACs, Staff H and Staff I, did not complete the mandated training hours. Staff H, hired in February 2022, lacked documentation of completing the required 12 hours of training for the period from February 2023 to February 2024. Similarly, Staff I, hired in August 2023, had only completed 6.10 hours of education by July 30, 2024, falling short of the required 12 hours. This deficiency was identified through a review of employee records and confirmed in an interview with the Director of Nursing Services (DNS), who acknowledged the expectation for NACs to complete the annual training requirement.
Deficiency in Diabetic Management for a Resident
Penalty
Summary
The facility failed to provide adequate care and services for a resident with diabetes mellitus type 2, resulting in a significant deficiency in managing the resident's blood glucose levels. The resident, who was cognitively intact, experienced a hypoglycemic episode with a blood glucose level as low as 47 mg/dL. Despite having a continuous glucose monitoring system, the resident's hypoglycemic episode was not documented in the progress notes, and the physician was not notified until 26 days later, leading to a delay in adjusting the resident's insulin order. The resident reported feeling fearful during the hypoglycemic episode, which occurred in the early morning hours. The resident's glucose monitor alarmed, but no staff responded to the call light, prompting the resident to seek help independently. The resident wheeled themselves to the nurse's station, where they were given juice and a peanut butter and jelly sandwich, but it took about an hour for their blood glucose to return to an acceptable range. The incident was not documented in the resident's clinical record, and the continuous glucose monitoring system's data was not cross-referenced with the medical record. Interviews with staff revealed inconsistencies in the reporting and documentation of the resident's low blood glucose levels. Staff members were unable to recall specific details of the incident, and there was no policy or procedure in place for using or gathering information from the continuous glucose monitoring system. The lack of documentation and timely notification to the physician placed the resident at risk for further complications and highlighted a deficiency in the facility's diabetic management practices.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to ensure the behavioral health needs of Resident 2 were identified and met. Resident 2, who was admitted with diagnoses including hip fracture, leukemia, chronic pain, anxiety disorder, and adjustment disorder with depressed mood, exhibited significant post-operative disorientation, agitation, and confusion. Despite these symptoms, the facility did not adequately address Resident 2's behavioral health needs. The resident's care plan included interventions for antidepressant and hypnotic medication use, but non-pharmacological interventions were not documented, and episodes of restless agitation were not reported to the provider. Additionally, Resident 2 experienced multiple episodes of depressive statements, refusal of care, withdrawal from activities, and disrobing, which were not effectively managed or documented by the staff. Resident 2's behavioral health concerns were not consistently addressed by the facility's medical staff. Progress notes from various medical professionals, including doctors and nurse practitioners, did not document or address Resident 2's behavioral health symptoms. Despite the resident's ongoing confusion, restlessness, and refusal of care, the facility's staff did not implement or document effective person-centered behavioral interventions. Interviews with staff members revealed a lack of consistent reporting and documentation of Resident 2's behavioral health issues, with some staff members stating that interventions were vague and not specific to the resident's needs. Observations and interviews with Resident 2 and staff members highlighted the resident's ongoing distress and unmet needs. Resident 2 was frequently found lying in bed uncovered and undressed, with their call light out of reach. The resident reported feeling neglected and in pain, with staff members failing to respond to their calls for help. Staff interviews indicated that behavioral interventions were not effectively communicated or implemented, and the resident's refusal of care and other behavioral symptoms were not adequately addressed. The facility's failure to identify and meet Resident 2's behavioral health needs resulted in a diminished quality of life for the resident.
Failure to Ensure Timely Medication Administration for New Admissions
Penalty
Summary
The facility failed to ensure pharmacy services were provided to meet the needs of three residents upon their admission. Resident 1, who was admitted with diagnoses including aftercare for heart bypass surgery, anxiety, and depression, did not receive their prescribed tramadol for pain management on the day of admission. The medication was only administered the following day, causing the resident to experience significant pain. The facility's process for acquiring and administering the medication was not followed, leading to a delay in pain relief for the resident. Resident 2, admitted with diagnoses including diabetes and leukemia, did not receive their prescribed medications, Steglatro and Imatinib Mesylate, on the scheduled dates. The MAR showed that the medications were not administered due to a need for prior authorization and high cost, which was only approved later in the day. This delay in medication administration was not properly documented or communicated, resulting in missed doses for the resident. Resident 3, admitted with a diagnosis of Parkinson's disease, did not receive their prescribed carbidopa-levodopa medication until the day after admission. The facility's staff failed to ensure the timely administration of this critical medication, which is essential for managing the resident's condition. Interviews with staff revealed inconsistencies in the medication administration process and a lack of proper documentation, contributing to the deficiencies observed in the care of these residents.
Unsanitary Shower Room Conditions
Penalty
Summary
The facility failed to provide a clean and sanitary environment in the residents' shower room, which negatively impacted Resident 4's desire to bathe. During an interview, Resident 4 described the shower room as filthy, with black grout and a dirty tub, leading them to prefer bed baths over showers. Observations confirmed the presence of black debris on the threshold and north wall of the shower room. Staff C, a Nursing Assistant Certified, mentioned that they only wiped down the shower stall with sanitizer wipes after each use and noted that housekeeping cleaned the shower room weekly. Staff D from housekeeping acknowledged the presence of built-up grime and attributed it to the building's age. The tub was also noted to be non-functional, contributing to the unsanitary conditions.
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 187 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) |
|---|---|---|---|---|
| Mt Baker Care Center | 0.9 mi | ★★★★★ | 2 | 0 |
| Shuksan Rehabilitation And Health Care | 2.8 mi | ★★★★★ | 5 | 0 |
| Avalon Healthcare Bellingham | 4.3 mi | ★★★★★ | 15 | 0 |
| Alderwood Park Health And Rehab Of Cascadia | 5.2 mi | ★★★★★ | 14 | 0 |
| North Cascades Health And Rehabilitation | 7.3 mi | ★★★★★ | 45 | 1 |
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