Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Everett Transitional Care Services during CMS and state inspections, most recent first.
A resident with multiple mobility and medical conditions suffered a second-degree burn after a CNA heated soup and served it without confirming a safe temp. The resident spilled the hot soup while eating, and records showed redness, blisters, and later a circumferential burn. The facility’s microwave reheating policy required temping food before service, but staff could not confirm the soup was checked, and no incident investigation was completed at the time.
Respiratory Care Deficiencies: The facility failed to provide respiratory care in accordance with accepted standards for three residents receiving O2. Residents were repeatedly observed with unlabeled and undated O2 tubing, oxygen equipment left out of bags, and no O2-in-use signs posted on room doors. One resident had no physician order directing when tubing should be changed, another had an order that conflicted with the TAR documentation, and staff stated the expected practice was weekly tubing changes with labeling and door signage.
The facility failed to include respiratory and mental health needs in care plans for two residents on O2 and one resident with dementia, anxiety, major depressive disorder, and psychotropic medication use. Although the residents had active O2 orders and were observed wearing NC oxygen, their care plans had no respiratory focus areas, goals, or interventions, and staff confirmed no respiratory care plan existed. One resident’s care plan also did not address dementia or mental health needs despite MDS, CAA, and PASRR findings.
Improper storage and labeling of insulin was found on a medication cart when a resident’s glargine insulin pen had no date showing when it was first used and another resident’s lispro insulin had been opened for 34 days. Facility policy and manufacturer guidance reviewed with the LPN and DON stated opened insulin is generally good for 28 days, and both residents were still receiving the medications.
The facility failed to update care plans for four residents, leading to potential health risks. A resident with tremors required feeding assistance, but their care plan lacked directives. Another resident on psychotropic medications had no care plan for monitoring side effects. A resident with a Stage 4 pressure ulcer had no care plan interventions, and a resident with urinary retention had no care plan references to their condition. Staff relied on care plans for guidance, highlighting the deficiency in updates.
The facility did not complete annual performance reviews for five NACs employed for over a year. Interviews and record reviews showed that evaluations for these staff members were not conducted, and the staff responsible for development acknowledged the oversight and were working on establishing a system to ensure compliance.
The facility failed to serve meals on time and at a palatable temperature on the 5th floor, with residents receiving cold meals due to delayed delivery. A resident complained about cold soup, and another required assistance to eat but was left waiting. Staff attributed delays to late meal cart arrivals, while the administration was unaware of the issue.
The facility failed to provide two nurse aides with the required 12 hours of in-service training and did not ensure that five nurse aides received mandatory dementia training. This deficiency was acknowledged by the staff development nurse and the administrator, who were in the process of implementing systems to address the training gaps.
Two residents in an LTC facility did not receive timely assistance with eating, despite being dependent on staff due to conditions like essential tremors and severe cognitive impairment. Observations showed delays in meal assistance, with trays left untouched for extended periods. The DON acknowledged the issue and noted the need for additional support for one resident.
A facility failed to follow physician orders for a resident with cardiac issues and diabetes. Hydralazine was administered despite low diastolic blood pressure, and elevated blood sugar levels were not reported to the physician as required. Staff interviews revealed a lack of documentation and adherence to orders, compromising the resident's care.
A facility failed to ensure consistent communication and collaboration with a dialysis center for a resident with end-stage renal disease. The resident's care plan lacked specific interventions and responsibilities, and numerous dialysis communication forms were missing or incomplete. The DON acknowledged the issue, noting that the kidney center did not always return the completed forms.
A facility failed to implement a pharmacist's recommendations for a resident's medication management, including increasing dapagliflozin dosage and monitoring for orthostatic hypotension. Staff interviews revealed a lack of awareness and documentation, placing the resident at risk for medication-related complications.
A facility failed to ensure a resident was free from unnecessary psychotropic medications due to a lack of valid diagnosis and non-pharmacological interventions. The resident, with diagnoses including Parkinson's Disease and dementia, was prescribed Abilify without proper behavior monitoring or care plan updates. Staff interviews revealed a lack of awareness regarding appropriate indications for antipsychotic use, contributing to the deficiency.
Unsafe heated food service led to resident burn injury
Penalty
Summary
The facility failed to prevent an accident for one resident when staff heated soup and did not ensure it was at a safe temperature before serving it. The resident had diagnoses including rheumatoid arthritis, diabetes, kidney disease requiring dialysis, chronic pain, gait and mobility abnormalities, bilateral below-the-knee amputations, and lack of coordination, and the MDS documented no cognitive impairment. The resident was dependent on two staff for transfers with a mechanical lift, dependent on one staff for bed mobility, toileting, and dressing, and required set-up assistance for meals but could feed themself. On the night of the incident, a CNA heated a bowl of soup for the resident and placed it at the edge of the bedside table before leaving the room to get a towel. The resident stated they began eating, their hand twitched, and the bowl fell and spilled onto them. The resident reported the soup was hot and they yelled for help. The progress note documented the resident had spilled a bowl of hot soup onto themself and had redness over the left groin, lower left abdomen, left hip, and part of the left lower back, with four dime-sized blisters. Pain medication was given, but the EMR did not show a skin check or pain evaluation for the burn incident. A wound consultant later documented a circumferential second-degree burn on the resident’s left lower leg, mainly on the thigh, with blisters, open areas, and loss of epidermis, measuring 15 cm by 58 cm by 0.1 cm. The facility’s microwave reheating policy required foods and fluids heated in the microwave to be served at safe temperatures and temperature taken prior to service, with hot foods and beverages served at less than or greater than 145 degrees. Staff interviews showed heated food should be temped before serving, but the staff member involved could not recall whether the soup had been temped. The facility also did not complete an investigation at the time of the incident, and the state reporting log showed the burn was documented without a completed investigation.
Respiratory Care Deficiencies
Penalty
Summary
The facility failed to ensure respiratory care and services were provided in accordance with accepted professional standards of practice for Residents 14, 15, and 41. The report states that the facility did not ensure oxygen tubing was changed routinely, did not have appropriate physician orders for oxygen administration, and did not have oxygen warning signs posted on resident doors. The facility policy titled, Oxygen Administration, dated 2025, required oxygen tubing and nasal cannulas to be changed weekly, nebulizer tubing and delivery devices to be changed every 72 hours, oxygen delivery devices to be kept covered in a plastic bag when not in use, and oxygen warning signs to be placed outside the resident’s room when oxygen was in use. Resident 14 had diagnoses including chronic lung diseases and was observed wearing oxygen via nasal cannula on multiple occasions. During observations, the oxygen tubing had no label or date, the nebulizer unit and tubing were hanging off the nightstand and were not in a bag, and no oxygen-in-use sign was posted on the door. A review of the physician orders dated 12/10/2025 showed no order directing staff when to change the oxygen tubing. Staff G stated Resident 14 did not have an active physician order for tubing changes, that tubing should be changed weekly and labeled and dated when changed, and that an oxygen-in-use sign should be posted outside the room. Resident 15 was observed wearing oxygen via nasal cannula on several occasions, and the oxygen tubing had no label or date while no oxygen-in-use sign was posted on the door. The physician orders dated 12/09/2025 directed staff to date and change the resident’s oxygen tubing twice a month, but the November 15th-30th 2025 TAR showed checkmarks indicating the tubing was changed every day. Staff H stated oxygen tubing was normally changed weekly, and Staff G stated the order had been entered incorrectly in the EMR and that the tubing should be changed weekly with a label and date. Resident 41 was also observed wearing oxygen via nasal cannula on multiple occasions, with no label or date on the tubing and no oxygen-in-use sign posted on the door. A review of Resident 41’s physician orders dated 12/09/2025 showed no order directing staff when to change the oxygen tubing, and Staff G stated there was no physician order for tubing changes and that an oxygen-in-use sign should be posted outside the room.
Incomplete Care Plans for Oxygen Therapy and Mental Health Needs
Penalty
Summary
The facility failed to develop comprehensive care plans that included all provided nursing services for two sampled residents who were receiving oxygen therapy and for one sampled resident reviewed for unnecessary medications related to mental health. Facility policy required comprehensive, person-centered care plans with measurable objectives and time frames, and the oxygen administration policy required care plans to identify the type of oxygen delivery system, when to administer or discontinue oxygen, flow rates, monitoring of oxygen levels, and monitoring for complications. Resident 41 was observed multiple times wearing oxygen via nasal cannula at 2 liters per minute, and the physician's order directed continuous oxygen via nasal cannula at 2 lpm. Resident 15 was also observed multiple times wearing oxygen via nasal cannula, with an active order for continuous oxygen via nasal cannula at 2 lpm to keep oxygen rates above 92% and to change and date oxygen tubing twice a month. Review of the care plans for Resident 41 and Resident 15 showed no resident focus areas, goals, or interventions for respiratory care, and staff confirmed there was no respiratory care plan for either resident. Resident 41 also had diagnoses including dementia, anxiety, and major depressive disorder, and the comprehensive MDS and PASRR documented antianxiety and antidepressant medication use, psychotropic drug use, serious mental illness, and severe cognitive impairment. Despite these findings and the CAAs indicating psychotropic drug use was triggered and would be addressed in the care plan, Resident 41's care plan contained no focus areas, goals, or interventions for dementia or mental health needs. Staff stated mental health was not addressed in the care plan even though they expected it to be.
Improper Storage and Dating of Insulin on Medication Cart
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when insulin products were not properly stored and labeled on Medication Cart 4. During observation, review, and interview, the facility was found to have a glargine insulin pen for one resident with no date showing when it was first used. The same cart also contained another resident’s lispro insulin that had been opened and dated 11/06/2025, which was 34 days old at the time of review. The facility policy titled Medication Storage stated insulin products should be stored in the refrigerator until opened, with the date noted on the label when first used, and that opened insulin vials may be stored in the refrigerator or at room temperature. Manufacturer recommendations reviewed for lispro and glargine documented the insulin was good for 28 days once opened and stored at room temperature. Staff F, LPN, stated insulin was good for 28 days after it was removed from the refrigerator, opened, and stored at room temperature, and stated both residents were still receiving these insulins. The DON stated the facility followed the manufacturer’s recommendations regarding how long insulins were good after opening and removal from the refrigerator.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise care plans for four residents, leading to potential risks for their health and well-being. Resident 57, who was admitted with essential tremor and mobility issues, required assistance with eating. However, the care plan did not include directives for feeding assistance, resulting in the resident waiting for help to eat their meals. Observations showed that the resident's lunch trays were left untouched until staff provided assistance, indicating a lack of proper care plan updates. Resident 43, diagnosed with dementia, depression, and psychosis, was on antidepressant and antipsychotic medications. The care plan lacked focus, goals, or interventions related to these medications, including monitoring for side effects or target behaviors. Staff interviews confirmed that the care plan should have included these details, but they were missing, leaving staff without necessary guidance for medication management. Resident 11, admitted with morbid obesity, muscle weakness, heart failure, and depression, had a Stage 4 pressure ulcer. The care plan did not address the wound or include interventions like the use of an air mattress and trapeze bar, which were observed during the resident's care. Similarly, Resident 3, with urinary retention and a history of septic shock, had no care plan references to their condition or catheter management. Staff interviews revealed reliance on care plans for resident care directives, highlighting the deficiency in updating and revising these plans to reflect residents' current needs.
Failure to Conduct Annual NAC Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for five Nurse Aide Certified (NAC) employees who had been employed for over a year. This deficiency was identified through interviews and record reviews, revealing that Staff J, P, Q, R, and S did not receive the required evaluations. Staff T, a Registered Nurse/Staff Development, acknowledged the absence of evaluations and mentioned being new to the position and in the process of establishing structures to ensure evaluations were completed. Additionally, Staff A confirmed awareness of the incomplete evaluations and stated efforts were underway to develop a new system to ensure compliance with educational requirements.
Delayed and Cold Meal Service on 5th Floor
Penalty
Summary
The facility failed to ensure that meals were served in a timely manner and at a palatable temperature on the 5th floor, as observed during a survey. The posted meal times for the 5th floor were not adhered to, with breakfast trays being delivered at 9:05 AM instead of the scheduled 8:35-8:45 AM. Similarly, lunch trays were delayed, with some residents receiving their meals as late as 2:10 PM, well past the scheduled time of 1:10-1:20 PM. This delay in meal delivery resulted in residents receiving cold meals, as evidenced by Resident 9's complaint about cold soup and Resident 30's consistent experience of cold meals. Several residents expressed dissatisfaction with the meal service, citing issues with the temperature and timeliness of the food. Resident 57, who required assistance with eating, was observed waiting for help while their meal remained untouched. Staff interviews revealed that the delay was attributed to meal carts arriving late from the kitchen, and the floor staff were distributing them as quickly as possible. However, the facility's administration, including the Administrator and Director of Nursing, were unaware of these issues, indicating a lack of communication and oversight regarding meal service on the 5th floor.
Deficiency in Nurse Aide Training and Dementia Education
Penalty
Summary
The facility failed to ensure that two of five nurse aides, identified as Staff P and S, received the required 12 hours of in-service training within the year. Additionally, all five nurse aides reviewed, identified as Staff J, P, Q, R, and S, did not receive the mandatory dementia training. This lack of training placed residents at risk of receiving less than competent care and services. During interviews, Staff T, a Registered Nurse/Staff Development, acknowledged being new to the position and was in the process of establishing structures to ensure required trainings and skills checks were completed for Nursing Assistants Certified (NACs). Furthermore, Staff A, the Administrator, was aware that the annual trainings had not been completed as required and was in the process of developing a new system to ensure compliance with educational requirements.
Failure to Provide Timely Eating Assistance
Penalty
Summary
The facility failed to provide necessary assistance for eating and drinking to two residents who were dependent on staff for these activities. Resident 57, who was admitted with essential tremors, muscle weakness, and lack of coordination, required supervision or touching assistance for eating. However, the care plan did not include the specific feeding assistance needed. Observations revealed that Resident 57 often had to wait for assistance long after meal trays were delivered, leading to meals being untouched for extended periods. Despite the resident's visible tremors and expressed need for help, staff were delayed in providing the necessary assistance. Resident 16, admitted with a history of stroke, dementia, and severe cognitive impairment, required extensive assistance for all activities of daily living, including eating. The care plan indicated total dependence on staff for feeding. However, observations showed delays in meal assistance, with staff attending to other tasks before assisting Resident 16. These delays in providing timely assistance for eating were acknowledged by the Director of Nursing Services, who noted the need for weighted utensils for Resident 57 and an Occupational Therapy evaluation.
Failure to Follow Physician Orders for Medication Administration and Notification
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards for Resident 21, who was admitted with cardiac diagnoses including congestive heart failure, hypertension, and diabetes. The facility did not adhere to the physician's orders regarding the administration of Hydralazine, a medication for hypertension, which was to be held if the resident's diastolic blood pressure (DBP) was less than 60. On multiple occasions, the medication was administered despite the DBP being below the threshold, specifically on 12/19/2024, 12/20/2024, 02/01/2025, and 02/08/2025. Additionally, the facility failed to notify the physician of elevated blood sugar levels that exceeded 400, as required by the physician's orders, on several dates in December 2024, January 2025, and February 2025. Interviews with facility staff, including the Director of Nursing Services and a Registered Nurse, revealed that the nurses may not have documented notifying the providers of the elevated blood sugars and did not follow the physician's orders to hold medications based on vital signs. The Director of Nursing Services acknowledged that the nurses should have documented these notifications in the medical record. The Registered Nurse confirmed that medications are to be held per physician's order and that providers should be notified and documentation made when blood sugars are below 60 or over 400.
Inadequate Communication and Documentation for Dialysis Care
Penalty
Summary
The facility failed to ensure consistent and ongoing communication and collaboration with the dialysis facility for a resident requiring dialysis services. Resident 21, who was admitted with end-stage renal disease and dependent on dialysis, had a care plan that lacked resident-centered interventions and collaboration between the nursing home and dialysis staff. The care plan did not specify the responsibilities of the facility and the dialysis center regarding the resident's care and medication. A review of the ECTS Dialysis Communication Form revealed numerous instances of missing or incomplete documentation regarding Resident 21's dialysis treatments. Specifically, there were twenty missing communication forms and five instances of incomplete assessment information. The Director of Nursing acknowledged the issue, noting that the kidney center did not always return the completed forms, which were necessary due to the resident's impaired vision. This lack of documentation and communication had the potential to cause unmet care needs and inadequate quality of care for the resident.
Failure to Implement Pharmacist's Recommendations for Medication Management
Penalty
Summary
The facility failed to act on the consultant pharmacist's medication regimen review (MRR) recommendations for a resident, leading to a deficiency in medication management. Resident 43, who was admitted with diagnoses including diabetes and long-term kidney disease, had a recommendation from the pharmacist to start dapagliflozin, an antidiabetic medication, and to increase the dosage if tolerated. Although the provider agreed with this recommendation, the dosage was not increased as planned, and there was no documented rationale for maintaining the initial dosage. Additionally, the MRR recommended regular monitoring for orthostatic hypotension due to antipsychotic use, but this was not documented in the resident's medical record. Interviews with facility staff revealed a lack of awareness and documentation regarding the pharmacist's recommendations. Staff I, a Registered Nurse, and Staff F, a Licensed Practice Nurse/Resident Care Manager, were unsure why the dapagliflozin dosage was not increased and confirmed the absence of orthostatic hypotension monitoring. The Director of Nursing, who was not employed at the facility during the initial recommendation, also could not provide an explanation for the oversight. This lack of action and documentation placed Resident 43 at risk for medication-related complications.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, as there was no valid diagnosis for the use of such medications, and non-pharmacological interventions were not implemented. The resident, who was admitted with diagnoses including Parkinson's Disease, stroke, dementia without behaviors, and depression, was prescribed Abilify, an antipsychotic, for dementia. However, there was no behavior monitoring or interventions associated with the use of this medication, and the care plan did not reflect the use of an antipsychotic or document any symptoms or behaviors related to its use. The facility's policy on the use of psychotropic medications was not followed, as evidenced by the lack of ongoing evaluation of the medication's effects and the absence of a supporting diagnosis for the use of Abilify. The pharmacist's review recommended checking the indication for the medication, but this was not addressed. Interviews with staff revealed a lack of awareness regarding the appropriate indications for antipsychotic use and insufficient monitoring of the resident's symptoms. The resident's care plan and assessments did not adequately address the use of psychotropic medication, leading to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Everett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany At Pacific | 1.2 mi | ★★★★★ | 0 | 0 |
| View Ridge Care Center | 1.9 mi | ★★★★★ | 16 | 0 |
| Madison Post Acute | 2.9 mi | ★★★★★ | 1 | 0 |
| Mountain View Rehabilitation And Care Center | 5.6 mi | ★★★★★ | 9 | 0 |
| Everett Center | 5.8 mi | ★★★★★ | 15 | 0 |
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