Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
North Cascades Health and Rehabilitation
BELLINGHAM, WA · 122 certified beds · Last Life Safety survey April 13, 2026
CMS Certification Number 505393 · first certified September 1991
Ownership
Operated by EVERGREEN HEALTHCARE GROUP · For profit - Limited Liability company
- Ownership changed August 31, 2023 (change of ownership)to NORTH CASCADES HEALTH & REHABILITATION CENTER from EVERGREEN AT BELLINGHAM LLC
Position within WA
27 citations — more than 39% of the 193 certified nursing homes in WA. Compared within WA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 7 citations; the earlier surveys in the window averaged 10. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens March 2027 — about 6 months from now. This facility’s last Life Safety survey was April 2026. Facilities in WA are typically surveyed 12–15 months after the last one (median 13), measured over 320 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
14 of the 27 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
13 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 27 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0926 Have policies on smoking.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
How that compares
Compared with the median facility in WA, and nationally. Surveyors differ markedly between states, so the WA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 27 |
| Median facility in WA | 31 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 8, 2024 | 13 |
| January 24, 2025 | 7 |
| April 13, 2026 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0029 | Develop a communication plan. | 3 | 2026-04-13 |
| E-0020 | Establish policies and procedures including evacuation. | 2 | 2026-04-13 |
| E-0036 | Establish emergency prep training and testing. | 2 | 2026-04-13 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-01-24 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2025-01-24 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 2 | 2025-01-24 |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 1 | 2026-04-13 |
| E-0037 | Establish staff and initial training requirements. | 1 | 2024-03-08 |
What the citations cover
- Emergency Preparedness Deficiencies 14
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Smoke Deficiencies 3
- Miscellaneous Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 14 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Smoke Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
| Egress Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 13, 2026 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (April 26, 2026) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (April 26, 2026) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (April 26, 2026) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (April 26, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 26, 2026) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (April 26, 2026) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (April 26, 2026) |
January 24, 2025 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (January 31, 2025) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (January 31, 2025) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (January 31, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (January 31, 2025) |
March 8, 2024 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (April 8, 2024) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (April 8, 2024) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (April 8, 2024) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (April 8, 2024) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (April 8, 2024) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (April 8, 2024) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (April 8, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (April 12, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 26, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (April 8, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 8, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (April 8, 2024) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (April 8, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.