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
Chain footprint
27 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 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
0.69
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.38
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.82
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.90
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
2.08
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
4.24
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
4.08
CMS adjusted total nurse staffing hours
Case-mix index
1.64
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
2,553
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.08
Composite VBP score used to determine payment impact.
Payment multiplier
1.0029
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.29
Baseline 20.87% · Performance 18.98% · Measure score 5.29 · Achievement 5.29 · Improvement 4.42
Healthcare-associated infections
6.88
Baseline 6.28% · Performance 5.78% · Measure score 6.88 · Achievement 6.88 · Improvement 3.39
Total nurse turnover
3.05
Baseline 42.86% · Performance 51.22% · Measure score 3.05 · Achievement 3.05 · Improvement 0
Adjusted total nurse staffing
4.41
Baseline 5.17 hours · Performance 4.33 hours · Measure score 4.41 · Achievement 4.41 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.75% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 188 · Observed rate 8.51% · Lower 95% interval 7.39% |
| Discharge to community | 67.87% |
50.57%
17.3 pts better
|
Better than the National Rate · Eligible stays 201 · Observed rate 62.19% · Lower 95% interval 59.42% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.06% |
95.27%
0.8 pts better
|
Numerator 122 · Denominator 127 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 127 |
| Discharge self-care score | 39.81% |
53.69%
13.9 pts worse
|
Numerator 41 · Denominator 103 |
| Discharge mobility score | 40.78% |
50.94%
10.2 pts worse
|
Numerator 42 · Denominator 103 |
| Pressure ulcers or injuries, new or worsened | 0.79% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 127 · Adjusted rate 0.78% |
| Healthcare-associated infections requiring hospitalization | 5.78% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 137 · Observed rate 3.65% · Lower 95% interval 3.49% |
| Staff COVID-19 vaccination coverage | 2.03% |
8.2%
6.2 pts worse
|
Numerator 3 · Denominator 148 |
| Staff flu vaccination coverage | 7.43% |
42%
34.6 pts worse
|
Numerator 15 · Denominator 202 |
| Discharge function score | 50.49% |
56.45%
6 pts worse
|
Numerator 52 · Denominator 103 |
| Transfer of health information to provider | 99.12% |
95.95%
3.2 pts better
|
Numerator 112 · Denominator 113 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 67.74% |
25.2%
42.5 pts better
|
Numerator 42 · Denominator 62 |
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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 100.0% |
| 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 · Q1 3.2% · Q2 3.1% · Q3 3.0% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| 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 · Q1 67.7% · Q2 73.3% · Q3 43.3% · Q4 29.0% · 4Q avg 53.3% |
| 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 · Q1 3.3% · Q2 3.7% · Q3 0.0% · Q4 3.0% · 4Q avg 2.5% |
| 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 · Q1 6.7% · Q2 10.3% · Q3 12.5% · Q4 12.1% · 4Q avg 10.5% |
| 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 · Q1 8.0% · Q2 4.8% · Q3 17.4% · Q4 14.3% · 4Q avg 11.3% · 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 | 25.0% |
20.0%
5 pts worse
|
16.3%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.0% · Used in QM five-star |
| 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 · Q1 40.7% · Q2 32.0% · Q3 11.1% · Q4 23.3% · 4Q avg 26.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.8% · Used in QM five-star |
| 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 · Q1 36.2% · Q2 30.7% · Q3 21.9% · Q4 19.6% · 4Q avg 26.9% |
| 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 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 1.7% · 4Q avg 0.9% · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · Adjusted 9.9% · Observed 9.5% · Expected 10.7% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.0% · 4Q avg 0.5% · Used in QM five-star |
| 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 · 4Q avg 100.0% |
| 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 · Adjusted 21.4% · Observed 20.3% · Expected 22.6% · Used in QM five-star |
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
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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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
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
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