Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Mt Baker Care Center during CMS and state inspections, most recent first.
Failure to report and investigate an alleged abuse incident. A cognitively intact resident reported waking up naked with three men groping them after being isolated in a private room during a COVID-related room change. The resident said the allegation was told to a NAC, who stated the information was only shared verbally with a nurse or care manager and no grievance report or statement was completed. Other NACs said they would tell a nurse about abuse allegations, but did not indicate they would report to the State Agency, and the facility’s logs showed no grievance or incident for the resident.
A resident with vesicointestinal and colovaginal fistulas, and moderate cognitive impairment, had an ADL care plan and Kardex directing that only showers be provided due to urinary and GI fistulas. Review of NAC documentation showed the resident was given a bath instead of a shower, and the NAC confirmed documenting a bath despite acknowledging that care plans and Kardex are used to determine required care and that shower and bath have different documentation codes. The RN/DNS stated staff are expected to follow the care plan and not provide baths when only showers are ordered, demonstrating a failure to provide care according to physician orders and the resident’s care plan.
A resident with severe dementia was prescribed Risperidone without a valid behavioral diagnosis, contrary to facility policy and FDA guidelines. Staff and pharmacy review confirmed that the medication was ordered for dementia with behavioral disturbances, but no specific behaviors or non-pharmacological interventions were documented, and the facility's monthly psychotropic medication review failed to identify the inappropriate diagnosis.
Surveyors found that the facility did not develop or update care plans to address the current needs of three residents, including one with edema requiring elastic stockings and diuretics, one seeking discharge to independent living, and one with dementia whose care plan lacked individualized behavioral interventions. Staff interviews confirmed that essential care planning elements were missing or outdated.
A resident with dementia and peripheral vascular disease was not consistently provided with the care-planned intervention of floating their heels while in bed, as required by physician orders and documented in their care plan. Multiple observations found the resident's heels resting on the mattress, and staff interviews confirmed inconsistent implementation of this pressure ulcer prevention measure.
Three residents receiving high-risk medications, including anti-coagulants and diuretics, did not have appropriate care plans or monitoring in place for side effects such as bleeding, bruising, or edema. One resident on Eliquis and another on Apixaban were not monitored for bleeding, with one experiencing blood in the urine and requiring hospitalization. Another resident on Lasix for edema had no documented monitoring for swelling or side effects, despite ongoing issues. Staff interviews confirmed the lack of required monitoring and care planning for these medications.
Staff did not implement Enhanced Barrier Precautions for a resident with a chronic, open pressure ulcer on the right heel, despite facility guidelines requiring such precautions for chronic wounds. Observation and staff interviews confirmed that EBP was not in place, and staff were either unaware of or acknowledged the lack of required infection control measures.
A resident with a documented allergy to sulfa antibiotics was administered Bactrim DS on two occasions, despite the allergy being noted in their clinical record and flagged by the pharmacy. The resident experienced a light rash and oral discomfort. Staff interviews revealed that there was an expectation to check for allergies, but no specific policy was in place.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to follow its abuse and neglect policy after an allegation of abuse involving one resident. The policy required allegations of abuse and neglect to be reported to the appropriate authorities and investigated. The resident was admitted to the facility and was assessed on the MDS as cognitively intact, with no mood or behavior symptoms. Review of the facility’s April and May 2026 grievance and incident logs showed no grievance or incident involving the resident. The resident’s family member reported that the resident had been isolated in a private room during a COVID-related room change and later described waking up naked with three men in the room groping them. The family member stated the resident felt like they had been drugged, that the room was dark, and that the individuals did not want to be seen. The resident also reported the incident directly, stating they woke up with no clothes or covers on and three males standing around groping them. The resident said they felt frozen and could not speak, and that they believed they may have been drugged because they are usually a light sleeper. The resident reported the incident to a NAC, Staff B, and said Staff B seemed to know this was occurring. Staff B stated the resident told them a man was standing over them while they were on the Medicare Hall, and that they verbally shared the information with a nurse or care manager but did not complete a grievance report or statement. Staff C vaguely recalled something involving the resident but could not remember the circumstances. Other NAC staff interviewed stated they would tell a nurse if a resident reported abuse, but did not indicate they would report the allegation to the State Agency. The DON stated after the interviews that the facility needed more training.
Failure to Follow Care Plan for Bathing Method
Penalty
Summary
The facility failed to ensure a resident received care in accordance with physician orders and the individualized care plan regarding bathing method. The resident was admitted with vesicointestinal and colovaginal fistulas and had an Activities of Daily Living (ADL) care plan and Kardex, both initiated on 07/21/2025, specifying that the resident was to receive only showers due to their urinary and gastrointestinal fistulas. The admission MDS dated 07/27/2025 documented a BIMS score of 09, indicating moderate cognitive impairment. Despite these documented directives, review of the NAC documentation for August 2025 showed that on 08/21/2025 the resident received a bath. During interviews, the NAC who provided care stated they reviewed the care plan and Kardex to determine the type of care and assistance needed and acknowledged that the documentation code for a shower was different from that for a bath. The NAC confirmed documenting that the resident received a bath on 08/21/2025. The RN/DNS stated that care plans are used to ensure staff know how to provide residents’ personal care and that staff were expected to follow the care plan and not give baths when only showers were ordered. The surveyors concluded that the facility did not provide care according to the resident’s orders and care plan, as required by WAC 388-97-1060(1)(2)(c).
Failure to Ensure Appropriate Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication use, specifically Risperidone, without a valid supporting diagnosis. The facility's policy requires all medications to be supported by a documented diagnosis or clinical rationale. Resident 45, who had severe cognitive impairment and a diagnosis of dementia, was observed to be calm, easily redirectable, and not exhibiting psychotic behaviors. Despite this, the resident had an active order for Risperidone for 'dementia with behavioral disturbances.' Staff interviews confirmed that the diagnosis of dementia alone was not appropriate for Risperidone use, and there was no documentation of specific behaviors or attempts at non-pharmacological interventions prior to starting the medication. Further review revealed that the medication was initiated at a previous assisted living facility due to reported behaviors, but the documentation lacked details of alternative interventions or a specific behavioral diagnosis. The facility's monthly psychotropic medication review process failed to identify the inappropriate diagnosis for the medication. Both the pharmacist and the Director of Nursing acknowledged that the diagnosis was not appropriate and that the oversight was not caught during routine audits.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed the current medical status and nursing services for multiple residents. For one resident with lower extremity edema and vascular wounds, there were physician orders for elastic stockings and diuretic therapy, but the care plan did not include interventions or monitoring related to edema, use of elastic stockings, or diuretic side effects. Staff interviews confirmed that these aspects were missing from the care plan and should have been included. Another resident with multiple sclerosis, epilepsy, and recent leg fractures expressed a desire to be discharged to an independent living facility. Although social services had assisted with the process and documented ongoing discharge planning in progress notes, there was no current or active discharge care plan in place. Staff interviews confirmed the absence of a discharge care plan despite the resident's ongoing interest and involvement in discharge planning. A third resident with dementia had a care plan that addressed cognitive impairment but did not include all known behaviors or individualized approaches used by staff, such as specific redirection techniques and personal preferences. Staff described various dementia-related behaviors and interventions used in practice, but these were not reflected in the written care plan. The Director of Nursing confirmed that care plans are expected to be updated with changes in condition and to communicate necessary care interventions.
Failure to Consistently Implement Heel-Floating Intervention for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when a resident with dementia, high blood pressure, and peripheral vascular disease was not consistently provided with care-planned interventions to prevent pressure ulcers, as required by their care plan and physician's orders. The resident's care plan and Kardex specified that their heels should be floated while in bed to maintain skin integrity, and the Treatment Administration Record included a physician order for this intervention. Despite these directives, multiple observations over several days found the resident in bed with their heels resting directly on the mattress, rather than being floated as required. Interviews with staff revealed that while some staff attempted to reposition the resident and float their heels, the intervention was not consistently implemented. Staff noted that the resident often slid down in bed, causing their heels to rest on the mattress, and that the resident sometimes requested the pillow used for floating be removed. The LPN/Case Manager was unaware of the issue with the resident sliding down, and the DON acknowledged the need for documentation of refusals and creative preventative measures. The failure to consistently implement the heel-floating intervention as ordered constituted the deficiency.
Failure to Monitor and Care Plan for High-Risk Medications
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary drugs due to a lack of monitoring and care planning for high-risk medications. For one resident with a history of aortic valve stenosis and atrial fibrillation, there was no care plan addressing the use of Eliquis (an anti-coagulant), and no interventions or monitoring for signs and symptoms of bleeding or bruising were developed, despite the resident receiving the medication twice daily. Similarly, another resident with recent cardiac surgery was administered Apixaban without a care plan or monitoring for side effects, even though the resident had a history of bleeding issues and was later observed with blood in the catheter bag, leading to hospitalization after continued bleeding and low blood pressure. Additionally, a third resident with vascular wounds and lower extremity edema was prescribed Lasix and elastic stockings for edema management, but there was no monitoring for edema or side effects of the diuretic therapy documented in the medical record. Observations confirmed the resident continued to experience swelling and had a history of sores on the legs, yet no monitoring was in place. Interviews with staff confirmed that monitoring for anti-coagulants and diuretics was not included in the care plans or medication orders for these residents. Staff acknowledged that the electronic medical record system did not prompt for side effect monitoring for these high-risk medications, and that such monitoring should have been included in the baseline care plans for new admissions receiving these drugs.
Failure to Implement Enhanced Barrier Precautions for Resident with Chronic Wound
Penalty
Summary
Staff failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic pressure ulcer on the right heel, which was discovered after removal of a hard cast and remained open, requiring ongoing dressing changes. During observation, no EBP measures were in place for this resident, despite facility guidelines requiring gowns and gloves for residents with chronic wounds. Interviews with the Infection Preventionist, the resident's case manager (LPN), and the Director of Nursing confirmed that EBP should have been in place for this resident, but staff were either unaware of the current precautions or acknowledged that EBP was not implemented as required. The deficiency was identified through observation, record review, and staff interviews, which collectively demonstrated a failure to follow established infection control guidelines for residents at increased risk for multi-drug-resistant organism transmission.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of two doses of an antibiotic listed on a resident's allergy list. Resident 1, who had a documented allergy to sulfa antibiotics, was administered Bactrim DS (a sulfa antibiotic) on two occasions. This error occurred despite the allergy being clearly noted in the resident's clinical record and flagged by the pharmacy. The resident experienced a light rash and oral discomfort, although it was unclear if these symptoms were directly related to the antibiotic administration. Interviews with facility staff revealed that there was an expectation for nurses to check for allergies when processing and administering medications, but there was no specific policy in place to enforce this practice. Staff members acknowledged the error and confirmed that the allergy was documented in the resident's records. The pharmacy had also notified the facility about the allergy, but the medication was still administered. The Director of Nursing Services stated that nurses were expected to follow the eight rights of medication administration and not administer medications on the resident's allergy list without special consent.
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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.
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Nursing homes near Bellingham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Health And Rehabilitation Of Cascadia | 0.9 mi | ★★★★★ | 5 | 0 |
| Shuksan Rehabilitation And Health Care | 2.6 mi | ★★★★★ | 5 | 0 |
| Avalon Healthcare Bellingham | 4.1 mi | ★★★★★ | 15 | 0 |
| Alderwood Park Health And Rehab Of Cascadia | 4.7 mi | ★★★★★ | 14 | 0 |
| North Cascades Health And Rehabilitation | 6.9 mi | ★★★★★ | 45 | 1 |
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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.