17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Seattle, WA
4-star overall rating with 3-star inspections with $38,565 in total fines with 17 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
2611 S Dearborn Street, Seattle, WA
(206) 712-6500
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
165
Certified beds
Average residents
71
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Evergreen Healthcare Group
Operator or chain grouping
Approved since
2020-12-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
41 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
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
1.48
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.17
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
4.81
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
7.46
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
2.65
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
6.66
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
1.37
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.44
CMS adjusted RN staffing hours
Adjusted total hours
7.25
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
3,244
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.3
Composite VBP score used to determine payment impact.
Payment multiplier
0.9985
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.59
Baseline 18.86% · Performance 19.77% · Measure score 3.59 · Achievement 3.59 · Improvement 0
Healthcare-associated infections
0
Baseline 5.77% · Performance 10.63% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
10
Baseline 6.17 hours · Performance 7.27 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.35% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 13.64% · Lower 95% interval 6.76% |
| Discharge to community | 25.47% |
50.57%
25.1 pts worse
|
Worse than the National Rate · Eligible stays 32 · Observed rate 3.13% · Lower 95% interval 14.06% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 91.49% |
95.27%
3.8 pts worse
|
Numerator 43 · Denominator 47 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 47 |
| Discharge self-care score | 12.5% |
53.69%
41.2 pts worse
|
Numerator 4 · Denominator 32 |
| Discharge mobility score | 12.5% |
50.94%
38.4 pts worse
|
Numerator 4 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 47 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 10.63% |
7.12%
3.5 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 29.41% · Lower 95% interval 6.61% |
| Staff COVID-19 vaccination coverage | 2.84% |
8.2%
5.4 pts worse
|
Numerator 4 · Denominator 141 |
| Staff flu vaccination coverage | 44.69% |
42%
2.7 pts better
|
Numerator 80 · Denominator 179 |
| Discharge function score | 25% |
56.45%
31.5 pts worse
|
Numerator 8 · Denominator 32 |
| 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 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 40% |
25.2%
14.8 pts better
|
Numerator 10 · Denominator 25 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.4
0.9 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 4.3 · Expected 3.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 2.2 · Expected 2.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
96.0%
0.9 pts better
|
93.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 94.1% · Q3 97.5% · Q4 98.8% · 4Q avg 96.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
93.8%
2.4 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
2.6%
1.2 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.3% · Q4 2.5% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
16.3%
13.1 pts better
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 7.6% · Q4 2.9% · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
5.8%
0.2 pts better
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 6.7% · Q3 1.8% · Q4 5.8% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.1% |
12.1%
2 pts worse
|
19.6%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 14.7% · Q3 15.4% · Q4 19.0% · 4Q avg 14.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.7% |
15.9%
8.8 pts worse
|
16.7%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 31.5% · Q3 20.9% · Q4 21.3% · 4Q avg 24.7% · 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 | 10.6% |
20.0%
9.4 pts better
|
16.3%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
15.8%
7.1 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 9.4% · Q3 6.8% · Q4 10.4% · 4Q avg 8.7% · 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 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.7%
1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 1.3% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.6% |
23.5%
3.9 pts better
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 19.3% · Q3 18.0% · Q4 21.9% · 4Q avg 19.6% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
4.7%
2 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.8% · Q3 6.8% · Q4 7.4% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.0% |
87.7%
9.7 pts worse
|
81.7%
3.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 72.2% · Q2 70.7% · Q3 85.7% · Q4 91.3% · 4Q avg 78.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.4% |
13.2%
8.8 pts better
|
12.0%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.4% · Observed 5.6% · Expected 14.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.6% |
1.4%
2.2 pts worse
|
1.6%
2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.5% |
82.0%
9.5 pts better
|
79.7%
11.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.8% |
19.9%
3.1 pts better
|
23.9%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 25.0% · Expected 35.5% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
11 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2025-10-20
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-10-20
Fire Safety
Meet other general requirements.
Corrected 2025-10-20
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-10-20
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-10-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-20
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-10-20
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-10-20
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-10-20
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-10-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-20
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-10-20
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-10-20
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-10-20
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 2025-10-20
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-10-20
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-08-01
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-01
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 2023-04-09
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-04-09
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-04-09
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-09
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-09
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-09
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-04-09
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 2023-04-09
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-09
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-04-09
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-09
Inspection history
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Not marked corrected
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Not marked corrected
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-29
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-29
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-10-29
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-10-29
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-29
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-10-29
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 2025-10-29
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-29
Health
Assess the resident when there is a significant change in condition
Corrected 2025-10-29
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-10-29
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 2025-10-29
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-10-29
Health
Provide activities to meet all resident's needs.
Corrected 2025-10-29
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-29
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-10-29
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-17
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-12-17
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-07-11
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-07-11
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 2024-07-11
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-11
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 2024-07-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-11
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-07-11
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-07-11
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-11
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-11
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-07-11
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 2024-07-11
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-07-11
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-11
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-07-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-08
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-11-16
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-19
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-04-05
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-05
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-04-05
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-04-05
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 2023-04-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-05
Penalties and ownership
Fine · fine $38,565
Fine
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
5% Or Greater Security Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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