15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Everett, WA
3-star overall rating with 3-star inspections with 15 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
5129 Hilltop Road, Everett, WA
(425) 258-4474
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
70
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Regency Pacific Management
Operator or chain grouping
Approved since
1989-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.69
Registered nurse staffing
LPN hours / resident day
1.38
Licensed practical nurse staffing
Aide hours / resident day
2.82
Nurse aide staffing
Weekend hours
4.24
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.0%
4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
2.6%
0.3 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 53.3% |
16.3%
37 pts worse
|
11.4%
41.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.5% |
5.8%
3.3 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.5% |
12.1%
1.6 pts better
|
19.6%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 11.3% |
15.9%
4.6 pts better
|
16.7%
5.4 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 | 25.0% |
20.0%
5 pts worse
|
16.3%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.6% |
15.8%
10.8 pts worse
|
14.9%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.2%
0.7 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.9% |
23.5%
3.4 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 0.9% |
4.7%
3.8 pts better
|
5.1%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
87.7%
12.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.9% |
13.2%
3.3 pts better
|
12.0%
2.1 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.4%
0.9 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
82.0%
18 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
19.9%
1.5 pts worse
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
17 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Fire safety
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-11-26
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-09-27
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-09-27
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-09-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-27
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-27
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-27
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-09-27
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-27
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-06-13
Fire Safety
Develop a communication plan.
Corrected 2023-06-12
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-06-21
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-21
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-06
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-06
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-12
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-06-21
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-06-12
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-06-21
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-06-13
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-06-21
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-06-12
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-30
Fire Safety
Meet other general requirements.
Corrected 2023-05-30
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-12
Inspection history
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2026-01-20
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-20
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2026-01-20
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2026-01-20
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-01-20
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2026-01-20
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 2026-01-20
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2026-01-20
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-01-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-20
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2026-01-20
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-20
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 2026-01-20
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2026-01-20
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-01-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-11
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 2024-09-30
Health
Assess the resident when there is a significant change in condition
Corrected 2024-09-30
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-30
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-09-30
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-30
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-30
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-30
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 2024-09-30
Health
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Corrected 2024-09-30
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-30
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-12
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 2023-06-12
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-12
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-06-12
Penalties and ownership
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Nearby options
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