Cycle 1
Health 2025-12-15 · Fire 2025-12-15
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Everett, WA
Everett Transitional Care Services
5-star overall rating with 5-star inspections with $21,863 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
916 Pacific Avenue, Everett, WA
(425) 382-2800
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
62
Certified beds
Average residents
44
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2020-06-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.83
Registered nurse staffing
LPN hours / resident day
0.72
Licensed practical nurse staffing
Aide hours / resident day
2.87
Nurse aide staffing
Weekend hours
4.84
Weekend nurse staffing
RN turnover
64%
Annual RN turnover
Total nurse turnover
55%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
96.0%
0.8 pts worse
|
93.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.0% |
93.8%
8.8 pts worse
|
95.5%
10.5 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
2.6%
0.8 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 27.2% |
16.3%
10.9 pts worse
|
11.4%
15.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.6% |
5.8%
5.2 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.2% |
12.1%
5.1 pts worse
|
19.6%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 13.3% |
15.9%
2.6 pts better
|
16.7%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.1% |
20.0%
5.9 pts better
|
16.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.7% |
15.8%
4.1 pts better
|
14.9%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.2%
0.5 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
1.7%
0.1 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.0% |
23.5%
7.5 pts better
|
19.8%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
4.7%
1.1 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.6% |
87.7%
1.9 pts better
|
81.7%
7.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.4%
0.7 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.2% |
82.0%
0.8 pts worse
|
79.7%
1.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-02-14 · Fire 2025-02-14
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2024-04-01 · Fire 2024-04-01
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-15
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2026-01-13
F · Potential for more than minimal harm
2025-12-15
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2026-01-13
F · Potential for more than minimal harm
2025-12-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2026-01-13
F · Potential for more than minimal harm
2025-12-15
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2026-01-13
F · Potential for more than minimal harm
2025-02-14
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-03-19
F · Potential for more than minimal harm
2025-02-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-19
F · Potential for more than minimal harm
2025-02-14
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-19
F · Potential for more than minimal harm
2024-04-01
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-04-01
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-04-01
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-04-01
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-04-01
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-04-01
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-04-01
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-04-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-04-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-04-01
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-04-01
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-01-22
D · Potential for more than minimal harm
2025-12-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-22
D · Potential for more than minimal harm
2025-12-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-22
E · Potential for more than minimal harm
2025-02-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-02-14
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-02-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-02-14
F947 · Nursing and Physician Services Deficiencies
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 2025-03-25
D · Potential for more than minimal harm
2025-02-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-14
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-03-25
E · Potential for more than minimal harm
2024-04-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-04-01
F761 · Pharmacy Service Deficiencies
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 2024-04-26
D · Potential for more than minimal harm
2024-04-01
F625 · Resident Rights Deficiencies
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 2024-04-26
D · Potential for more than minimal harm
2024-04-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-04-01
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-04-26
G · Actual harm
2023-07-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-29
Penalties and ownership
What sits behind the stars
$21,863
2023-07-26
Fine
Fine · fine $21,863
Fine
Ownership
Bethany Of The Northwest
5% Or Greater Direct Ownership Interest · Organization
Providence Health & Services-Wa
5% Or Greater Direct Ownership Interest · Organization
Bauguess, Tristine
Operational/Managerial Control · Individual
Bethany Of The Northwest
Operational/Managerial Control · Organization
Block, Allison
Corporate Director · Individual
Combs, Scott
Corporate Director · Individual
Degroodt, Patricia
Corporate Director · Individual
Hovey, John
Operational/Managerial Control · Individual
Jacobson, Steven
Corporate Director · Individual
Lemke, Kristi
Operational/Managerial Control · Individual
Onerheim, Paul
Corporate Officer · Individual
Peterson, Jason
Corporate Director · Individual
Scrivens, Joseph
Operational/Managerial Control · Individual
Scrivens, Joseph
Corporate Officer · Individual
Nearby options
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4-star overall rating with 3-star inspections with $42,477 in total fines with 18 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
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Everett, WA
3-star overall rating with 3-star inspections with 15 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Madison Post Acute
Everett, WA
3-star overall rating with 3-star inspections with $71,318 in total fines with 15 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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