Everett, MA

Rehabilitation & Nursing Center At Everett (The)

4-star overall rating with 4-star inspections with 6 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle

289 Elm Street, Everett, MA

(617) 387-6560

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

0 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

183

Certified beds

Average residents

148

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Personal Healthcare Management

Operator or chain grouping

Approved since

1987-04-10

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

19 facilities

Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars

Changed ownership

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

0.65

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

0.80

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.14

Nurse aide staffing · state 2.26 · national 2.35

Total nurse hours

3.58

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.44

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.23

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.37

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.76

CMS adjusted RN staffing hours

Adjusted total hours

4.22

CMS adjusted total nurse staffing hours

Case-mix index

1.16

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

29%

Annual nurse turnover · state 40% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,103

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

51.73

Composite VBP score used to determine payment impact.

Payment multiplier

1.0061

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.86

Baseline 19.23% · Performance 19.18% · Measure score 4.86 · Achievement 4.86 · Improvement 0

Healthcare-associated infections

5.15

Baseline 6.23% · Performance 6.30% · Measure score 5.15 · Achievement 5.15 · Improvement 0

Total nurse turnover

7.14

Baseline 41.30% · Performance 34.48% · Measure score 7.14 · Achievement 7.14 · Improvement 3.65

Adjusted total nurse staffing

3.54

Baseline 3.61 hours · Performance 4.08 hours · Measure score 3.54 · Achievement 3.54 · Improvement 1.69

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	8.69%	10.72% 2 pts better	No Different than the National Rate · Eligible stays 116 · Observed rate 4.31% · Lower 95% interval 5.87%
Discharge to community	52.4%	50.57% 1.8 pts better	No Different than the National Rate · Eligible stays 62 · Observed rate 38.71% · Lower 95% interval 37.7%
Medicare spending per beneficiary	0.75	1.02 0.3 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 79 · Denominator 79
Falls with major injury	1.27%	0.77% 0.5 pts worse	Numerator 1 · Denominator 79
Discharge self-care score	26.79%	53.69% 26.9 pts worse	Numerator 15 · Denominator 56
Discharge mobility score	33.93%	50.94% 17 pts worse	Numerator 19 · Denominator 56
Pressure ulcers or injuries, new or worsened	1.27%	2.29% 1 pts better	Numerator 1 · Denominator 79 · Adjusted rate 1.6%
Healthcare-associated infections requiring hospitalization	6.29%	7.12% 0.8 pts better	No Different than the National Rate · Eligible stays 67 · Observed rate 4.48% · Lower 95% interval 3.4%
Staff COVID-19 vaccination coverage	17.53%	8.2% 9.3 pts better	Numerator 27 · Denominator 154
Staff flu vaccination coverage	49.74%	42% 7.7 pts better	Numerator 95 · Denominator 191
Discharge function score	51.79%	56.45% 4.7 pts worse	Numerator 29 · Denominator 56
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	21.74%	25.2% 3.5 pts worse	Numerator 10 · Denominator 46

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.5	1.9 0.4 pts better	1.9 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.3	1.5 0.8 pts worse	1.8 0.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.2 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	92.4%	92.2% 0.2 pts better	93.4% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 95.0% · Q3 92.2% · Q4 84.2% · 4Q avg 92.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.6%	94.8% 3.8 pts better	95.5% 3.1 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6%
Percentage of long-stay residents experiencing one or more falls with major injury	1.4%	3.5% 2.1 pts better	3.3% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.1% · Q3 1.4% · Q4 0.7% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.5%	12.0% 8.5 pts better	11.4% 7.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 3.1% · Q3 6.0% · Q4 3.8% · 4Q avg 3.5%
Percentage of long-stay residents who lose too much weight	3.4%	5.2% 1.8 pts better	5.4% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.4% · Q3 3.9% · Q4 2.3% · 4Q avg 3.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	20.1%	19.2% 0.9 pts worse	19.6% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 19.7% · Q3 18.4% · Q4 19.1% · 4Q avg 20.1%
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	12.3%	17.7% 5.4 pts better	16.3% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 8.4% · Q3 5.8% · Q4 15.6% · 4Q avg 12.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	13.9%	17.6% 3.7 pts better	14.9% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 11.6% · Q3 8.5% · Q4 18.9% · 4Q avg 13.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.5%	1.0% 0.5 pts better	1.0% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.7% · Q3 0.7% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.9%	2.0% 1.1 pts better	1.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.4% · Q4 0.7% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	3.0%	21.7% 18.7 pts better	19.8% 16.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.8% · Q3 2.5% · Q4 4.4% · 4Q avg 3.0%
Percentage of long-stay residents with pressure ulcers	3.0%	4.6% 1.6 pts better	5.1% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.1% · Q3 4.1% · Q4 4.6% · 4Q avg 3.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	73.0%	77.1% 4.1 pts worse	81.7% 8.7 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 77.5% · Q3 61.5% · Q4 58.5% · 4Q avg 73.0%
Percentage of short-stay residents who had an outpatient emergency department visit	19.6%	11.8% 7.8 pts worse	12.0% 7.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 22.7% · Expected 13.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.0%	1.3% 0.3 pts better	1.6% 0.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	79.1%	77.7% 1.4 pts better	79.7% 0.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 79.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	17.1%	25.8% 8.7 pts better	23.9% 6.8 pts better	Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 16.7% · Expected 23.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-07 · Fire 2025-08-07

6 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

12 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 2 Health 2024-08-28 · Fire 2024-08-28

13 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-08-31 · Fire 2023-08-31

12 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

2 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-08-07

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2025-09-20

F · Potential for more than minimal harm 2025-08-07

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-09-20

F · Potential for more than minimal harm 2025-08-07

K222 · Egress Deficiencies

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 2025-09-20

F · Potential for more than minimal harm 2025-08-07

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2025-09-20

F · Potential for more than minimal harm 2025-08-07

K321 · Smoke Deficiencies

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 2025-09-20

F · Potential for more than minimal harm 2025-08-07

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-09-20

F · Potential for more than minimal harm 2025-08-07

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-09-20

F · Potential for more than minimal harm 2025-08-07

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-09-20

F · Potential for more than minimal harm 2025-08-07

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-09-20

F · Potential for more than minimal harm 2025-08-07

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-09-20

F · Potential for more than minimal harm 2025-08-07

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-09-20

E · Potential for more than minimal harm 2025-08-07

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-09-20

F · Potential for more than minimal harm 2024-08-28

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-10-29

D · Potential for more than minimal harm 2024-08-28

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2024-10-29

D · Potential for more than minimal harm 2024-08-28

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-10-29

D · Potential for more than minimal harm 2024-08-28

K321 · Smoke Deficiencies

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 2024-10-29

D · Potential for more than minimal harm 2024-08-28

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-10-29

D · Potential for more than minimal harm 2024-08-28

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-10-29

F · Potential for more than minimal harm 2023-08-31

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2023-10-19

F · Potential for more than minimal harm 2023-08-31

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-10-19

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-08-07

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 2025-09-08

D · Potential for more than minimal harm 2025-08-07

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-09-08

D · Potential for more than minimal harm 2025-08-07

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 2025-09-08

D · Potential for more than minimal harm 2025-08-07

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-09-08

D · Potential for more than minimal harm 2025-08-07

F810 · Nutrition and Dietary Deficiencies

Health

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Corrected 2025-09-08

D · Potential for more than minimal harm 2025-08-07

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-09-08

E · Potential for more than minimal harm 2024-08-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-07

E · Potential for more than minimal harm 2024-08-28

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-28

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-28

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-28

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-28

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-28

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 2024-10-07

D · Potential for more than minimal harm 2024-08-28

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-28

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-28

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-28

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-28

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 2024-10-07

D · Potential for more than minimal harm 2024-08-28

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2024-10-07

E · Potential for more than minimal harm 2023-08-31

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-10-11

D · Potential for more than minimal harm 2023-08-31

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-10-11

D · Potential for more than minimal harm 2023-08-31

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-10-11

D · Potential for more than minimal harm 2023-08-31

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 2023-10-11

D · Potential for more than minimal harm 2023-08-31

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-10-11

D · Potential for more than minimal harm 2023-08-31

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 2023-10-11

D · Potential for more than minimal harm 2023-08-31

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2023-10-11

D · Potential for more than minimal harm 2023-08-31

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2023-10-11

D · Potential for more than minimal harm 2023-08-31

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 2023-10-11

D · Potential for more than minimal harm 2023-08-31

F790 · Quality of Life and Care Deficiencies

Health

Provide routine and 24-hour emergency dental care for each resident.

Corrected 2023-10-11

D · Potential for more than minimal harm 2023-08-31

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-10-11

D · Potential for more than minimal harm 2023-08-31