24 health deficiencies
Top issue: Resident Rights (7 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Bothell, WA
3-star overall rating with 2-star inspections with $106,698 in total fines with 24 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
707 - 228th Southwest, Bothell, WA
(425) 481-8500
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
99
Certified beds
Average residents
88
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
1.27
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.93
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
5.02
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
2.09
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
4.12
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.89
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.96
CMS adjusted RN staffing hours
Adjusted total hours
3.80
CMS adjusted total nurse staffing hours
Case-mix index
1.81
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
6,753
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9867
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.36
Baseline 15.02% · Performance 19.88% · Measure score 3.36 · Achievement 3.36 · Improvement 0
Healthcare-associated infections
4.72
Baseline 5.57% · Performance 6.42% · Measure score 4.72 · Achievement 4.72 · Improvement 0
Total nurse turnover
2.20
Baseline 52.94% · Performance 54.70% · Measure score 2.20 · Achievement 2.20 · Improvement 0
Adjusted total nurse staffing
2.45
Baseline 3.31 hours · Performance 3.77 hours · Measure score 2.45 · Achievement 2.45 · Improvement 1.39
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.96% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 426 · Observed rate 7.51% · Lower 95% interval 7.32% |
| Discharge to community | 59.22% |
50.57%
8.6 pts better
|
Better than the National Rate · Eligible stays 477 · Observed rate 52.62% · Lower 95% interval 54.37% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 96.25% |
95.27%
1 pts better
|
Numerator 231 · Denominator 240 |
| Falls with major injury | 1.25% |
0.77%
0.5 pts worse
|
Numerator 3 · Denominator 240 |
| Discharge self-care score | 76.22% |
53.69%
22.5 pts better
|
Numerator 125 · Denominator 164 |
| Discharge mobility score | 80.49% |
50.94%
29.5 pts better
|
Numerator 132 · Denominator 164 |
| Pressure ulcers or injuries, new or worsened | 3.75% |
2.29%
1.5 pts worse
|
Numerator 9 · Denominator 240 · Adjusted rate 3% |
| Healthcare-associated infections requiring hospitalization | 6.42% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 288 · Observed rate 5.56% · Lower 95% interval 4.45% |
| Staff COVID-19 vaccination coverage | 8.33% |
8.2%
0.1 pts better
|
Numerator 11 · Denominator 132 |
| Staff flu vaccination coverage | 35.82% |
42%
6.2 pts worse
|
Numerator 48 · Denominator 134 |
| Discharge function score | 80.49% |
56.45%
24 pts better
|
Numerator 132 · Denominator 164 |
| Transfer of health information to provider | 98.75% |
95.95%
2.8 pts better
|
Numerator 158 · Denominator 160 |
| Transfer of health information to patient | 93.48% |
96.28%
2.8 pts worse
|
Numerator 43 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 63.25% |
25.2%
38 pts better
|
Numerator 74 · Denominator 117 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.4
0.6 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.5 · Expected 3.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.3 · Expected 2.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
96.0%
1.8 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 97.9% · Q3 100.0% · Q4 97.8% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.8%
6.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
2.6%
0.6 pts worse
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.2% · Q3 4.2% · Q4 2.2% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 68.0% |
16.3%
51.7 pts worse
|
11.4%
56.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 69.8% · Q2 70.2% · Q3 65.2% · Q4 66.7% · 4Q avg 68.0% |
| Percentage of long-stay residents who lose too much weight | 9.9% |
5.8%
4.1 pts worse
|
5.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 2.4% · Q3 14.9% · Q4 10.0% · 4Q avg 9.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.2% |
12.1%
0.9 pts better
|
19.6%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 11.4% · Q3 14.9% · Q4 11.4% · 4Q avg 11.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
15.9%
5.8 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 8.8% · Q3 9.8% · Q4 16.2% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.1% |
20.0%
9.9 pts better
|
16.3%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.4% |
15.8%
2.6 pts worse
|
14.9%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 21.1% · Q3 10.0% · Q4 14.3% · 4Q avg 18.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.2%
0.9 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.9% |
23.5%
0.4 pts worse
|
19.8%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 25.5% · Q3 17.1% · Q4 21.7% · 4Q avg 23.9% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.7%
2.1 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.2% · Q3 2.1% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
87.7%
8.1 pts better
|
81.7%
14.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.9% · Q2 95.5% · Q3 95.1% · Q4 96.6% · 4Q avg 95.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.1% |
13.2%
1.9 pts worse
|
12.0%
3.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 14.9% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.4%
0.7 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.8% · Q3 0.7% · Q4 0.7% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
82.0%
16.5 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.2% |
19.9%
1.7 pts better
|
23.9%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.2% · Observed 19.0% · Expected 24.8% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (7 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Resident Rights (4 deficiencies)
20 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Provide primary/alternate means for communication.
Corrected 2025-04-25
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-25
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-25
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-25
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-02-16
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-02-16
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-02-16
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-02-16
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-16
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-16
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-02-16
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-02-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-16
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-02-16
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-16
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-04
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-16
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-02-16
Fire Safety
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.
Corrected 2024-02-16
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-02-16
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-02-16
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-02-16
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-16
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-16
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-10-31
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-10-31
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-10-31
Inspection history
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2025-07-11
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-05-14
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2025-05-14
Health
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.
Corrected 2025-05-14
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-14
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-14
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-14
Health
Keep all essential equipment working safely.
Corrected 2025-05-14
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-14
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-05-14
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-05-14
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-05-14
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-05-14
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-05-14
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-05-14
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2025-05-14
Health
Provide activities to meet all resident's needs.
Corrected 2025-05-14
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-14
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-05-14
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-14
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-05-14
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-05-14
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-05-14
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-11-04
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-03-05
Health
Post nurse staffing information every day.
Corrected 2024-03-05
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-03-05
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-05
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-03-05
Health
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.
Corrected 2024-03-05
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-05
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-05
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-03-05
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-03-05
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-05
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-05
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-03-05
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-03-05
Health
Implement a program that monitors antibiotic use.
Corrected 2024-03-05
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-01
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-11-01
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-06
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-14
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-11-14
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-14
Penalties and ownership
Fine · fine $42,764
Fine
Fine · fine $10,384
Fine
Fine · fine $53,550
Fine
Payment Denial · denial start 2023-06-02 · 4 days
4 day denial
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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