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
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
Hours and turnover
RN hours / resident day
1.83
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.87
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
5.41
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
2.54
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
4.84
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
1.34
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.68
CMS adjusted RN staffing hours
Adjusted total hours
4.96
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,623
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.37
Baseline 55.56% · Performance 58.06% · Measure score 1.37 · Achievement 1.37 · Improvement 0
Adjusted total nurse staffing
3.25
Baseline 3.62 hours · Performance 4 hours · Measure score 3.25 · Achievement 3.25 · Improvement 1.28
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 16 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5.88% |
8.2%
2.3 pts worse
|
Numerator 4 · Denominator 68 |
| Staff flu vaccination coverage | 7.04% |
42%
35 pts worse
|
Numerator 5 · Denominator 71 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
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 · Q1 95.8% · Q2 91.8% · Q3 97.4% · Q4 96.8% · 4Q avg 95.2% |
| 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 · 4Q avg 85.0% |
| 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 · Q1 2.1% · Q2 2.0% · Q3 2.6% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| 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 · Q1 18.2% · Q2 32.6% · Q3 33.3% · Q4 25.9% · 4Q avg 27.2% |
| 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 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| 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 · Q1 15.6% · Q2 17.4% · Q3 16.2% · Q4 20.7% · 4Q avg 17.2% |
| 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 · Q1 16.7% · Q2 13.3% · Q3 12.0% · Q4 10.0% · 4Q avg 13.3% · 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 | 14.1% |
20.0%
5.9 pts better
|
16.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.1% · Used in QM five-star |
| 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 · Q1 12.5% · Q2 11.9% · Q3 17.1% · Q4 3.6% · 4Q avg 11.7% · Used in QM five-star |
| 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 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| 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 · Q1 4.3% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| 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 · Q1 17.6% · Q2 15.3% · Q3 9.7% · Q4 22.4% · 4Q avg 16.0% |
| 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 · Q1 1.7% · Q2 2.9% · Q3 8.0% · Q4 2.2% · 4Q avg 3.6% · Used in QM five-star |
| 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 · Q1 87.3% · Q2 86.9% · Q3 89.4% · Q4 93.0% · 4Q avg 89.6% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 5.6% · Q4 1.8% · 4Q avg 2.1% · Used in QM five-star |
| 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 · 4Q avg 81.2% |
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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Bethany At Pacific
Everett, WA
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
View Ridge Care Center
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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